The Brook at High Falls Nursing Home and Rehabilitation Center
December 2, 2016 Certification Survey

Standard Health Citations

FF10 483.20(d);483.21(b)(1):DEVELOP COMPREHENSIVE CARE PLANS

REGULATION: 483.20 (d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident?s active record and use the results of the assessments to develop, review and revise the resident?s comprehensive care plan. 483.21 (b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident?s medical record. (iv)In consultation with the resident and the resident?s representative (s)- (A) The resident?s goals for admission and desired outcomes. (B) The resident?s preference and potential for future discharge. Facilities must document whether the resident?s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 2, 2016
Corrected date: January 31, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, it was determined that for one (Resident #3) of five residents reviewed for unnecessary medications, the facility did not develop a plan of care for each resident that includes measurable objectives, timetables and interventions to address care and treatment related to the clinical [DIAGNOSES REDACTED]. The issue involved the lack of a Comprehensive Care Plan for the use of an anticoagulant. This is evidenced by the following: Resident #3 has [DIAGNOSES REDACTED]. A physician order, dated 8/26/16, directs to hold [MEDICATION NAME] ([MEDICATION NAME]; antiplatelet agent used to inhibit blood clots in [MEDICAL CONDITION] and to prevent [MEDICAL CONDITION] and stroke) from 9/1/16 to 9/7/16, pending surgery. A Resident Plan of Care (directs daily cares), dated 10/10/16, does not include approaches or interventions for anticoagulant use. The area for anticoagulant use is blank. A physician order, dated 11/28/16, directs daily use of [MEDICATION NAME]. Observations and interviews conducted on 12/1/16 included the following: a. At 2:52 p.m., a Licensed Practical Nurse/Nurse Manager (LPN/NM) said she is responsible for writing Care Plans and there is usually one in place for the use of [MEDICATION NAME]. She reviewed the current Care Plans and Resident Plan of Care and said there was nothing documented regarding the use of an anticoagulant. She said maybe it was pulled from the medical record. b. At 3:15 p.m., the Unit Secretary said she found a Resident Plan of Care, dated 3/7/16, in overflow. The Resident Plan of Care documented on [MEDICATION NAME]--blood thinner. There were no interventions for anticoagulant use. During an interview on 12/2/16 at approximately 10:00 a.m., the LPN/NM said she initially added anticoagulant use to the Resident Plan of Care on 3/7/16, but it had fallen off, beginning with the 6/27/16 sheet. The LPN/NM said she did not find any Care Plan with anticoagulant use. She said there was no facility standard of care for anticoagulant use. She said she had looked in the medical record and overflow files and there is nothing for the use of [MEDICATION NAME] since admission in (MONTH) (YEAR). She said if it is not documented on the Resident Plan of Care, the Certified Nursing Assistants (CNAs) would not know what to look for with the resident. The LPN/NM said, at the very least, nurses should be cutting the resident's nails. Review of a facility policy, Comprehensive Care Plans, dated 9/2/16, directs that the facility develop a Care Plan for each resident that includes measurable objectives (goals) and timetables to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the Comprehensive Assessment. The CNA Resident Plan of Care, a significant part of the comprehensive care plan, will contain specifics of day to day personal care of the resident. Established Standards of Care are also considered a part of the Resident Care Plan. A review of the facility Standards of Care dated 11/5/14, did not include anticoagulant use. (10 NYCRR 415.11(c)(1))

Plan of Correction: ApprovedDecember 27, 2016

F279 A Care Plan was developed for Resident #3 on 12/2/16 and shared with the IDT.
All Residents on anticoagulant/antiplatelet therapy have the potential to be affected by the deficient practice. A care plan will be developed for each identified Resident.
Current policy & procedure will be reviewed and revised. Policy changes will be shared with all nurses at mandatory inservice 1/10/17. Care Plan Audits will be revised to include anticoagulant & antiplatelet therapy. Care plan audits will be done with each MDS.
The audit results will be shared with the QA Committee at each meeting until compliance is met then quarterly.
Responsible Party:(NAME)Jensen, RN, DON

FF10 483.10(a)(1):DIGNITY AND RESPECT OF INDIVIDUALITY

REGULATION: (a)(1) A facility must treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident?s individuality. The facility must protect and promote the rights of the resident.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 2, 2016
Corrected date: January 31, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, it was determined that for one (Resident #6) of three residents reviewed for dignity, the facility staff did not promote care for each resident in a manner that maintains or enhances dignity. Specifically, a staff interaction with a resident was loud. This is evidenced by the following: Resident #6 has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 9/16/16, revealed that the resident is cognitively intact, has minimal difficulty hearing, and wears a hearing aid. During an observation on 11/29/16 at 1:32 p.m., a Certified Nursing Assistant (CNA) startled the surveyor when she spoke in a loud voice to the resident in the main dining area. She touched his ear, and asked him where his hearing aid was. Interviews conducted on 11/30/16 included the following: a. At 9:01 a.m., the resident stated that not everyone treats him with respect and dignity. He said some staff members do not treat him nice. b. At 2:17 p.m., the Registered Nurse (RN) stated that she witnessed the CNA speaking loudly to the resident, and directed her to tone it down. The RN said the CNA continued with her loud voice, so she told the Nurse Manager. She said the CNA sometimes sounds like she is scolding and that is not dignified. The RN said the resident had one hearing aid in at that time, and that the other was sent home with his family for repair. Interviews conducted on 12/1/16 included the following: a. At 3:46 p.m., the CNA said that she has a loud voice, and the residents get used to it after a while. She said it is cultural. She said she did not feel initially as though she was loud, until she was told she startled others. She then commented that scolding a resident is inappropriate and she will try and watch her voice/tone in the future. b. At 5:00 p.m., the Nurse Manager stated that she was aware of the incident, and that it was not an appropriate way to speak to a resident. (10 NYCRR 415.5(a))

Plan of Correction: ApprovedDecember 22, 2016

F241 Resident #6 will be interviewed to ensure he wishes to continue being cared for by involved CNA. The CNA involved was counseled 12/2/16 by DON.
All current Residents and/or designated reps will be interviewed to ensure each Resident's dignity is being respected. Any allegations will be investigated and addressed with involved individuals.
Current policy and procedure will be reviewed and revised. Mandatory inservice is scheduled for 1/10/17.
The abuse audit will be revised to include monitoring dignity issues. The audit results will be shared with the QA Committee at each meeting until compliance is met then quarterly.
Responsible Party:(NAME)Jensen, RN, DON

FF10 483.90(d)(2)(e):ESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION

REGULATION: (d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition. (e) Resident Rooms Resident rooms must be designed and equipped for adequate nursing care, comfort, and privacy of residents.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 2, 2016
Corrected date: January 31, 2017

Citation Details

Based on observations, interviews, and record reviews, it was determined that the facility did not maintain all essential mechanical, electrical, and patient care equipment in safe operating condition. Specifically, oxygen concentrators had frayed cords, a pressure pump mattress had a hole in it, and none of these items were being maintained according to manufacturer's specifications. This is evidenced by the following: 1. Observations on 11/29/16 at 11:20 a.m. revealed the power lead to a 'New Life Elite' oxygen concentrator, located outside Resident Room #2, was frayed and the outer sheathing had pulled away from where the cord connects to the orange colored plug. 2. Observations on 11/29/16 at 1:15 p.m. revealed the power cord to an 'Invacare' brand oxygen concentrator, located in Resident Room #11, was frayed where the cord enters the machine. Additionally, an air filter on the right hand side of the unit was missing. Further observations of the same concentrator on 11/30/16 at 9:40 a.m. revealed the unit was in use in Resident Room #11, the cord was still frayed and the filter on the right side was missing. When interviewed at that time, the Nurse Manager stated that it was a safety hazard and she would change it out. She said the nursing staff is responsible for cleaning and changing the filters. A review of the Treatment Administration Record (TARS) for the resident in Room #11 did not include any entries related to cleaning or maintenance of the oxygen concentrator. When interviewed at that time, a Registered Nurse stated that there should be documentation related to the cleaning and maintenance of the oxygen concentrator in the TARS. A review of the manufacturer's specification for the 'Invacare' brand oxygen concentrator, located in Resident Room #11, revealed a preventative maintenance record MUST be used at a minimum for the concentrator. There was no documentation that the preventative maintenance for this unit was being completed. 3. Observations on 11/29/16 at 1:23 p.m. revealed a Lumex brand alternating pressure pump system attached to the bed closest to the window in Resident Room #10, was in use and running. There were no residents or staff members in the room at that time. A label affixed to the side of the unit was dated 8/15/15. In an interview on 11/30/16 at 1:20 p.m., a Maintenance Worker stated that they found a hole in the pressure pad in Resident Room #10 and took it out of service. The Maintenance Worker stated that the date on the side of the unit is when it was placed into service. A review of the manufacturer's specification for the 'Lumex' brand alternating pressure bubble pad and pump system revealed a warning not to leave this product unattended when plugged in. General maintenance procedures included to check the bubble pad for signs of wear or damage. There was no documentation to show the general maintenance procedures were completed for the aforementioned pressure pad and pump system observed in Resident Room #10. (10 NYCRR: 415.29(b))

Plan of Correction: ApprovedJanuary 3, 2017

F456 1) The frayed wire to the Oxygen Concentrator in Room #2 was repaired by Maintenance and put back into service on 11/30/16.
2) The frayed wire to the Oxygen Concentrator in room #11 was repaired by Maintenance and the filter replaced on 11/3016.
3) The Lumex brand alternating pressure pump system in room #10 was removed and replaced by nursing with a workable unit on 11/30/16.
The facility will maintain all essential mechanical, electrical, and patient care equipment including oxygen concentrators, pressure pad pumps in a safe operating condition per manufacturing specification thru routine inspection and required maintenance. 1/31/17. This will be monitored by the Administrator for compliance and any findings will be reported to the QA Committee.

FF10 483.25(d)(1)(2)(n)(1)-(3):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: (d) Accidents. The facility must ensure that - (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed?s dimensions are appropriate for the resident?s size and weight.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 2, 2016
Corrected date: January 31, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, it was determined that for one (Resident #26) of six residents reviewed for accident hazards, the facility did not ensure that the residents' environment remained as free of potential accident hazards as possible. Issues involved improper positioning of a bed and placement of a solid cement block on the floor near the head of the bed. This is evidenced by the following: Resident #26 has [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) Assessment, dated 11/7/16, revealed the resident's cognitive skills for daily decision making are moderately impaired and requires extensive assist of one for bed mobility. A Resident Plan of Care (directs daily cares), dated 10/24/16, directs bed against the wall but a revision, dated 11/7/16, does not include bed against wall (no check mark/blank). A Care Plan (CP) for Falls, dated 11/4/16, included approaches to provide low bed, wedges or landing pad and evaluate environment for hazards. A Fall Risk Evaluation, dated 11/7/16, revealed the resident is a high risk of falling. Review of an Incident Report, dated 11/17/16, revealed the resident was found kneeling between the bed and the wall, without visible injury. Measures to prevent reoccurrence included to move bed against the wall. In an interview on 11/29/16 at 8:39 a.m., a Licensed Practical Nurse/Nurse Manager (LPN/NM) said the resident had two falls within the last thirty days and had sustained an abrasion, like a rug burn, to the forehead. In observations on 11/29/16 at 11:07 a.m., and 1:42 p.m., the resident was in bed, sleeping, and the bed was not against the wall. Additionally, a solid cement block (measuring about 2 inches by 8 inches by 16 inches) was set on the floor, slightly behind the headboard, and extending outward toward the center of the room. In an observation on 11/30/16 at 3:09 p.m., the resident was in bed and the bed was not against the wall. The cement block was standing upright at the head of the bed. Interviews conducted on 12/2/16 included the following: a. At 8:35 a.m., Registered Nurse (RN) #1 observed the resident's bed and said it needed to be pushed against the wall. A cement block was set on the floor, upright, about 6 inches away from the head of the bed (moving towards foot of bed). RN #1 said the cement block was there to protect the electrical outlet, behind the headboard, in case the bed frame moved. She also said the block had been moved, it should be behind the headboard. RN #1 said she has real safety concerns about using cement blocks, especially when a resident has a history of falls from bed. She said this resident could fall out of bed and hit his head or somehow hurt himself. b. Between 8:49 a.m. to 8:56 a.m., the Director of Nursing (DON) observed the resident's bed and room and said the bed was not against the wall and should be against the wall. She observed the standing cement block and said it was unsafe and did not know how it got out from behind the headboard. c. At 9:11 a.m., the resident was in bed, the bed was not against the wall. CNA #1/Days/Primary and CNA #2 both said they did not know that the bed should be against the wall. CNA #1 added that she did not know the resident had fallen out of bed and was caught between the bed and the wall. She said, The way the bed is now, he could get caught in there again. At that time, the DON arrived and said the cement block had been placed behind the headboard and she had turned it horizontally versus vertically so it was more stable. (10 NYCRR 415.12(h)(1))

Plan of Correction: ApprovedDecember 27, 2016

F323 The Resident # 26's room was moved. No cement block was needed in the new room.
All resident rooms will be checked for cement blocks. Cement blocks, if needed, will be replaced with a 2 x 4 attached permanently to the floor. Room arrangements will be re-evaluated for need.
Current policy will be reviewed & revised regarding the use of 2 x 4 instead of cement block. Staff will be educated on policy change at mandatory inservice 1/10/17
This will be monitored for compliance and any issues will be reported to the QA committee.

Responsible Party:(NAME)T. Heard, Administrator

FF10 483.12(a)(3)(4)(c)(1)-(4):INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS

REGULATION: 483.12(a) The facility must- (3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 2, 2016
Corrected date: January 31, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, it was determined that for one (Resident #7) of one resident reviewed for abuse, the facility did not investigate an alleged incident of resident abuse to rule out abuse, neglect, or mistreatment. Specifically, there was a lack of a thorough investigation. This is evidenced by the following: Resident #7 has [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) Assessment, dated 9/30/16, revealed the resident's cognitive skills for daily decision making are moderately impaired and requires extensive assistance of one staff for bathing, dressing, and grooming needs. In an interview on 11/29/16 at 10:18 a.m., the resident said a staff member shook her and she reported the incident. On 11/30/16 at about 3:45 p.m., the surveyor requested Accident/Incident Reports (A/Is) for the last six months for the resident. The facility did not have any A/I Reports for the resident. Interviews conducted on 12/2/16 included the following: a. At 11:45 a.m., during the Abuse Prohibition Review, the Director of Nursing (DON) said she thought she had formally written a report, but after looking in her files, she could not find the investigation. The DON said she thought it was the Social Worker (SW) who brought the issue to her attention. b. At about 12 noon, the DON returned to surveyor with a copy of the resident's statement, dated 7/14/16, 3:30 p.m. The statement revealed that the resident reported her aide (Certified Nursing Assistant/CNA) throws her around like a dishrag. The resident was clutching her hands together, shaking, as she discussed her encounters with this CNA. The resident reported that the CNA grabbed her by the wrist and there are scratches on her back, arms, and belly. The resident stated, She scares the hell out of me. The DON said she thought she had interviewed the CNA, however was unable to find any documentation. The DON said she did not go back to interview the resident because she was so upset. The DON said, I'm not going to be able to produce the A/I. c. At 12:20 p.m., a Licensed Practical Nurse/Nurse Manager said for something like this, a full investigation needs to be completed. d. At 12:23 p.m., the SW said she took the resident's statement and then reported the incident to the team, on the same day. The SW said she expected a full investigation to follow, including a body check. She said she thought a Registered Nurse (RN) had completed a physical exam and documented in the Progress Notes (PNs). A review of PNs, dated 7/14/16 to 7/25/16, did not reveal any note regarding a skin assessment. e. At 3:35 p.m., a RN said she wrote a statement about the skin but was unable to locate the documentation. The RN said she remembered that the resident had scratches on her body, her side and arm. Review of a facility policy, Resident Abuse, undated, directs that residents shall be free from all types of abuse: verbal, sexual, physical, corporal punishment, involuntary seclusion and mental. This prohibition shall apply to any staff member, family member, visitor, contractor, consultant, volunteer or another resident. The facility shall investigate all alleged violations and will protect the resident from further potential abuse while the investigation is in progress. Alleged violations involving mistreatment, neglect, abuse or injuries of unknown origin and misappropriation of resident's property are reported immediately to the Administrator or his designee and the State Survey and Certification Agency. (10 NYCRR 415.4 (b) (3))

Plan of Correction: ApprovedDecember 22, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F225 The IDT met 12/20/16 to discuss incident for Resident #7 that occurred 7/13/16 and reported 7/14/16. Documents of events were recreated based on best recollection of team members. IDT discussed events in detail and believe all steps were taken to investigate the incident and protect Resident #7. The resident was examined by RN 7/14/16. Self inflicted scratches were the only injury noted. The employee involved was removed from Resident#7's assignment and restricted from entering Resident's room [ROOM NUMBER]/15/16. Resident was informed of changes and very happy. The CNA was eventually terminated 9/19/16 for attendance issues.
All current Residents and/or designated reps will be interviewed to ensure there are no other allegations noted, an investigation will be done.
The current policy and procedure will be reviewed and revised as needed. All management staff will be educated on steps to take to initiate investigations. Mandatory staff in-service on abuse is scheduled for 1/10/17.
Abuse audit will be revised to include monitoring of proper documentation after each incident. Audit results will be shared with QA Committee until compliance is met then quarterly.
Responsible Party:(NAME)Jensen, RN, DON

FF10 483.60(d)(1)(2):NUTRITIVE VALUE/APPEAR, PALATABLE/PREFER TEMP

REGULATION: (d) Food and drink Each resident receives and the facility provides- (d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance; (d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature;

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: December 2, 2016
Corrected date: January 31, 2017

Citation Details

Based on observations, interviews, and record reviews, it was determined that for 8 of 25 residents, the facility did not prepare or serve food that is palatable, attractive and at the proper temperature. The issues involved concerns that the food did not taste good and was not always served hot enough. This is evidenced by the following: Observations and interviews made during the lunch meal on 11/29/16 included the following: a. At 1:00 p.m. when asked how her Shepherd's Pie was, Resident #7 made a thumbs down gesture and said she had already requested a substitute. b. At about 1:15 p.m., Resident #31 said the food was okay, just very institutional. c. At 1:22 p.m., Resident #28 was eating in her room. She had eaten about ¾ of her Shepherd's Pie but nothing else. She said she had eaten it because it just takes too long when I ask for something else I wait a long time She also said the Shepherd's Pie had been served cold. The pellet bottom and plate felt cold to the touch, no warmth coming off of either. d. At 1:27 p.m., two pellets/plates served in the dining room were felt and both were cold, no warmth felt. e. At 1:30 p.m., Resident #15 was feeding herself pureed vegetables. When asked how her food tasted, she made a grimace, scrunching up her face. f. At about 1:32 p.m., Resident #4 had not eaten anything. His plate and pellet felt cold to the touch. He did not respond to surveyor questions. Observations and interviews made during the lunch meal on 11/30/16 included the following: a. At about 1:15 p.m., Cook #1 said a plate warmer is in use but pellet bottoms are not heated. b. At 1:48 p.m., Resident #8 said the potato salad does not taste homemade. I think it came out of a can. c. At about 1:50 p.m., Resident #6 said the potato salad is not good, it's all institutional, not homemade. During interviews on 12/1/16 at 10:06 a.m. and 10:27 a.m., a Registered Dietitian (RD) said she does not make formal meal rounds. The RD said she needs to be doing that. She said there was no plate waste audit in place that she knew of and that should be looked into. The RD added that she would have to see if the Director of Food Service (DFS) is monitoring plate waste. In an interview on 12/1/16 at 10:35 a.m., both Cook #1 and Cook #2 said there is no formal process in place to monitor or document food waste. Observations and interviews made during the lunch meal on 12/1/16 included the following: a. At 12:51 p.m., Cook #2 said, Nothing here is homemade. I did add garlic and onion to the spaghetti sauce, it comes as a plain marinara. b. At 1:21 p.m., Resident #6 and Resident #5 both said the spaghetti and meatballs are terrible, right out of a can. c. At 1:24 p.m., the DFS, two surveyors and a Licensed Practical Nurse/Nurse Manager (LPN/NM) sampled a Test Tray including spaghetti, meatballs, zucchini, tossed salad and bread. The meatballs and zucchini were described by all as okay. The DFS said that Mrs. Dash (seasoning blend) had been added to the zucchini. The LPN/NM said her spaghetti tasted a little bland and she would have liked some of the Mrs. Dash on it. She also described the salad dressing as warm. The DFS said the salad dressing had just been delivered that morning, and was not chilled yet. The DFS said the meatballs were a commercially made product. Food items tasted appropriately warm to all. In an interview on 12/2/16 at about 9:20 a.m., the DFS said she attends Resident Council meetings if she is available, otherwise, the Social Worker sends her meeting minutes. The DFS said there are only so many meal options and only so many things you can do with the menu. She said that after the first of the year, she and the new RD are going to re-evaluate the menu. The DFS said she has never made meal rounds and does not monitor the Daily Meal Monitor Board because she is not clinical. She said the RD does both. When asked when she would change a menu item, the DFS said Maybe if the meal board (monitor) was less than 50 percent. But the residents are old, don't like so much food and there are a lot of factors. If I am told consistently that residents don't like something, I might pull it off the menu but I can't take consumption as a sole factor completely for a menu change. A review of Daily Meal Monitor Boards, revealed: a. On 11/29/16, lunch meal: 16 of 24 recorded residents ate 50 percent or less. b. On 11/30/16, lunch meal: 16 of 25 recorded residents ate 50 percent or less. c. On 12/1/16, lunch meal for 25 residents: 10 of 18 recorded residents ate 50 percent or less. A review of Resident Council Meeting Minutes, dated September, (MONTH) and (MONTH) (YEAR), revealed comments that food is starting to get repetitive again, would like more variety, fresh fruits, vegetables are hard, including hard strings in the beans, food has continued to get better however, it still needs improvement. (10 NYCRR 415.14(2))

Plan of Correction: ApprovedDecember 22, 2016

F364 For the following residents Resident # 4,5,6,7,8,15,28,31, the Dietary Dept. will conduct
rounding audits for likes, dislikes and preferences for these residents starting 12/27/16 and to be completed for all residents by 1/31/17.The Food Service Manager and Dietitian will do this. Additionally it will be done on a quarterly basis with the MDS schedule and any changes will be documented on residents diet cards and in the Food Service Directors master lists so that this information is readily available tot he kitchen when preparing resident meals. The Dietitian will update nutrition care plans quarterly or as needed stating that residents like, dislikes, and preferences have been reviewed and updated. This will be monitored on a continuous basis by the Administrator and/or Nurse Manager for compliance and any findings will be report to the QA Committee.
F364 For the following residents #4,5,6,7,8,15,28,31 the issue with food temperatures at service will be monitored with a Dietary tray audit at meal service starting 12/27/16 and to be completed for all residents by 1/31/17 and monthly thereafter. This will be done by the care team and any findings will be addressed by the appropriate dept. This will be monitored by the Administrator for compliance and any findings will be reported to the QA Committee.
F364 For the following residents #4,5,6,7,8,15,28,31 and for all other residents menus will be revised based on resident preferences gathered from initial Dietary rounding interviews by 1/31/17 and menus will be adjusted accordingly. Any new menu items will trigger a dietary tray audit. The Food Service Manager and the Dietitian will do this. This will be monitored by the Administrator for compliance and any findings will be reported to the QA Committee.

FF10 483.35(g)(1)-(4):POSTED NURSE STAFFING INFORMATION

REGULATION: 483.35 (g) Nurse Staffing Information (1) Data requirements. The facility must post the following information on a daily basis: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law) (C) Certified nurse aides. (iv) Resident census. (2) Posting requirements. (i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift. (ii) Data must be posted as follows: (A) Clear and readable format. (B) In a prominent place readily accessible to residents and visitors. (3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard. (4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: December 2, 2016
Corrected date: January 31, 2017

Citation Details

Based on observation, interviews, and record reviews, it was determined that the facility did not post daily nurse staffing information. Specifically, the facility staffing sheets did not include the resident census and total number and actual hours worked by the staff. This is evidenced by the following: A review of the facility staffing sheets from 11/29/16 through 12/2/16, revealed that the facility census and total and actual hours that staff worked were not included in the posted information. During an interview on 12/2/16 at 9:30 a.m., the Unit Secretary and Director of Nursing, both stated that they did not know that the staff hours and census needed to be included on the daily staffing information. They both said, they thought it could be completed the following day.

Plan of Correction: ApprovedDecember 22, 2016

F356 All Nursing Management Staff were educated on regulation 12/2/16. Daily records were revised 12/2/16.
No other areas were identified at risk to be affected by this practice.
A policy and procedure will be developed to comply with this regulation. All staff will be educated on this regulation at mandatory in-service 1/10/17.
Daily monitoring will be performed by(NAME)Brackley, LPN. An audit will be conducted monthly to ensure compliance.
The audit results will be shared with the QA Committee at each meeting until compliance is met then quarterly.
Responsible Party:(NAME)Jensen, RN, DON

Standard Life Safety Code Citations

K307 NFPA 101:AISLE, CORRIDOR, OR RAMP WIDTH

REGULATION: Aisle, Corridor or Ramp Width 2012 EXISTING The width of aisles or corridors (clear or unobstructed) serving as exit access shall be at least 4 feet and maintained to provide the convenient removal of nonambulatory patients on stretchers, except as modified by 19.2.3.4, exceptions 1-5. 19.2.3.4, 19.2.3.5

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 2, 2016
Corrected date: January 31, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews conducted during the Life Safety Code Survey, it was determined that for one (1954 building) of three resident living spaces and one (1965 building) of three basements, the facility did not properly maintain egress width. Specifically, items were placed in egress corridors reducing the usable width. This is evidenced by the following: 1. Observations on 11/29/16 at 9:50 a.m. and again at 11:06 a.m., revealed the usable width of the egress corridor outside Rooms #15 and #17 (1954 building) was reduced to 26-inches by an Invacare mechanical lift stored in the hallway. When interviewed at approximately 3:00 p.m., the Certified Nursing Assistant (CNA) said that the lift is usually kept down near the nurses' station. 2. Observations on 11/29/16 at approximately 10:40 a.m., revealed the usable width of the egress corridor in the basement near the supply room (1965 building) was reduced to approximately 26-inches by a cat toy climbing tower stored in the hallway. 3. Observations on 11/30/16 at 10:12 a.m. and again at 1:24 p.m., revealed the usable width of the egress corridor outside Resident Rooms #15 and #17 (1954 building) was reduced to 26-inches by a mechanical lift stored in the hallway. When interviewed at that time, CNA #2 said the lift should be stored around the corner and is used to transfer the resident in room [ROOM NUMBER]. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101:19.2.3.4, 19.2.3.5; 2000 NFPA 101:19.2.3.3)

Plan of Correction: ApprovedDecember 23, 2016

K232 1) The Invacare mechanical lift when not in use will be kept in alcove of porch and not stored outside Rooms #15 and #17. The staff will be instructed on the proper storage of the lift. 1/10/17. This will be monitored on a continuous basis by the Administrator and will report any findings to the QA Committee.
2) The cat toy has been removed. The facility no longer has the cats. 12/12/16.
3) The Invacare mechanical lift when not in use will be kept near the nurses station and not stored outside Rooms #15 and #17. The staff will be instructed on the proper storage of the lift. 1/10/17 this will be monitored on a continuous basis by the Administrator and will report any findings to the QA Committee. The Administrator will also on a continuous basis check the facility for any other obstructed egress pathways and correct any deficient areas found

K307 NFPA 101:BUILDING CONSTRUCTION TYPE AND HEIGHT

REGULATION: Building Construction Type and Height 2012 EXISTING Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7 19.1.6.4, 19.1.6.5 Construction Type 1 I (442), I (332), II (222) Any number of stories non-sprinklered and sprinklered 2 II (111) One story non-sprinklered Maximum 3 stories sprinklered 3 II (000) Not allowed non-sprinklered 4 III (211) Maximum 2 stories sprinklered 5 IV (2HH) 6 V (111) 7 III (200) Not allowed non-sprinklered 8 V (000) Maximum 1 story sprinklered Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 2, 2016
Corrected date: January 31, 2017

Citation Details

Based on observations and record reviews conducted during the Life Safety Code Survey, it was determined that for one (1954 building) of three resident living spaces, the facility did not properly maintain a compliant building construction type. Specifically, a three-story wood framed section of the nursing home was used for housing residents. This is evidenced by the following: Observations on 11/29/16 at approximately 9:40 a.m. revealed the 1954 section of the facility consisted of three floors and a basement. The construction of this section appeared to be comprised primarily of wood as its structural vertical and horizontal elements. The second and third floors of the 1954 building were unoccupied, and the first floor level was observed to have three single resident sleeping rooms (#14, #15, and #17), and other occupied spaces including: the Director of Nursing office, the Social Work office, the Beauty Shop, a resident tub and bathroom, and a meeting room. The Centers for Medicare and Medicaid Services recognizes the 2001 edition of NFPA 101A, Guide on Alternative Approaches to Life Safety, (also known as the Fire Safety Evaluation System or FSES). This standard provides alternative approaches to life safety based on equivalent safety concepts. A building determined to have equivalent safety to the requirements of the NFPA 101, Life Safety Code, is deemed to be compliant for the identified deficient requirement. Review of a Fire Safety Evaluation System (FSES) performed on 5/5/16 revealed a passing score with subsequent equivalency granted by the New York State Department of Health as of 6/1/16. Please include your Plan of Correction or your request for continuation of the FSES in the space provided on this form. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101:19.1.6.1; 2000 NFPA 101:19.1.6.2)

Plan of Correction: ApprovedDecember 23, 2016

K161 The facility requests a continuation of the FSES that was approved by the New York State Department of Health as of 6/1/16 The Administrator will be responsible for updating the FSES to 2013 version prior to the next recertification survey

K307 NFPA 101:CORRIDOR - DOORS

REGULATION: Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 2, 2016
Corrected date: January 31, 2017

Citation Details

Based on observations and an interview conducted during the Life Safety Code Survey, it was determined that for one (1965 building) of three resident living spaces and one (1965 building) of three basements, the facility did not properly maintain corridor doors. Specifically, doors were obstructed from closing and a door was not resistant to the passage of smoke. This is evidenced by the following: 1. Observations on 11/29/16 at 1:30 p.m., revealed the top of the corridor door to Resident Room #5 (1965 building) was not resistant to the passage of smoke. When fully closed, there was an approximately 1/4 to 3/8 of an inch gap between the door and the frame that was 14-inches long and located in the upper right side of the frame. 2. Observations on 11/29/16 at 1:35 p.m., revealed the corridor door to the shower room located between Resident Rooms #4 and #6 (1965 building) was obstructed by a shower chair left in front of the door. The shower room was also used to store a large cart of clean linens. 3. Observations on 11/30/16 at 8:40 a.m., revealed the corridor door to the shower room located between Resident Rooms #4 and #6 (1965 building) was obstructed by a linen cart placed in front of the door. 4. Observations on 11/30/16 at approximately 1:05 p.m., revealed the corridor door to Resident Room #4 (1965 building) was obstructed by an over-bed tray table left in front of the door. 5. Observations on 12/1/16 at 11:30 a.m. and again at 11:53 a.m., revealed the corridor door to the basement maintenance shop/housekeeping supply room (1965 building) was propped open by two stacks of copy paper and no one was present in the room. An interview with a Housekeeper revealed the door was left propped open because the cats were in there. (10 NYCRR: 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101:19.3.6.3.1, 19.3.6.3.10; 2000 NFPA 101:19.3.6.3.1, 19.3.6.3.3)

Plan of Correction: ApprovedDecember 22, 2016

K363 1) Weather stripping was attached to the door of room #5 to close the gap between the door and the frame to make it resistant to the passage of smoke. 11/29/16. Maintenance will inspect all corridor doors to make sure they are resistant to the passage of smoke on a monthly basis. The Administrator will monitor this inspection and will report any findings to the QA Committee.
2) The shower chair was removed from the doorway to the shower room 11/29/16. The staff will be instructed not to place any object in the doorway to the shower room. This will be monitored on a continuous basis by the DON and will report any findings to the QA Committee, sign posted on shower room doors.
3) The linen cart was removed from the doorway to the shower room 11/30/16 The staff will be instructed not to place any object in the doorway to the shower room.This will be monitored on a continuous basis by the DON and will report any findings to the QA Committee.
4) The over -bed-table was removed from the doorway to room #4 11/30/16. The staff will be instructed not to place any object that would obstruct any corridor door from closing. This will be monitored on a continuous basis by the DON and will report any findings to the QA Committee.
5) The copy paper was removed from the corridor door to the maintenance room 12/1/16. The staff will be instructed not to place any object that would obstruct any corridor door from closing. This will be monitored on a continuous basis by the Administrator and will report any findings to the QA Committee.

K307 NFPA 101:ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS

REGULATION: Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 2, 2016
Corrected date: January 31, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and an interview conducted during the Life Safety Code Survey, it was determined that for three (1983, 1965, and 1954 buildings) of three resident living spaces and one (1965 building) of three basements, the facility did not properly maintain electrical equipment. Specifically, an extension cord was in use, power strips were used in series, power strips were used with patient care equipment, and a power strip was not properly mounted. This is evidenced by the following: 1. Observations on 11/29/16 from 8:45 a.m. to 1:40 p.m. revealed the following: a. There were bed controls and an alternating pressure pump and pad plugged into a tripplight brand power strip in Resident room [ROOM NUMBER] (1983 building). There were no markings on the power strip to indicate it was UL 1363-A or UL -1 rated. b. There was a power strip connected to a microwave in the staff dining room (1983 building) and the power strip was dangling (not mounted to the wall) behind the microwave. c. There was a gray extension cord in use and connected to a copy machine in the Social Work office (1954 building). The extension cord was also connected to a power strip. d. There were two power strips in use and connected to each other (daisy-chained) in the 1965 building basement boiler room. In an interview at that time, the Administrator stated the power strips were for the Internet. e. There were infrared bed side monitors plugged in to power strips in Resident Rooms #12 and #2 (1965 building). There were no markings on the power strips to indicate they were UL 1363-A or UL -1 rated. The 2012 edition of NFPA 99, Standard for Health Care Facilities, requires all adaptors to be listed for their purpose. The 2011 edition of NFPA 70, National Electric Code, requires flexible cord and flexible cable, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent. Flexible cords and cables shall not be used as a substitute for the fixed wiring of a structure. Guidance provided by the Centers for Medicare and Medicaid Services (Ref: S&C: 14-46-LSC) on 9/26/14 listed specific requirements for using power strips in conjunction. Power strips providing power to non-medical equipment in a resident rooms must be UL 1363. Power strips providing power to medical equipment in a resident room must be UL 1363A or UL -1. Power Strips cannot be daisy-chained. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.5.1, 9.1.2; 2000 NFPA 101: 19.5.1, 9.1.2; 2012 NFPA 99: 10.2.4.2.1; 2011 NFPA 70: 240.5, 400.8)

Plan of Correction: ApprovedDecember 22, 2016

K920 A The bed controls and the alternating pressure pump were unplugged from the power strip and plugged into the wall receptacle 11/29/16. Maintenance will inspect all resident rooms on a weekly basis to make sure all patient related equipment is plugged into the wall receptacles. This will be monitored on a continuous basis by the Administrator and will report any findings to the QA Committee.
B The power strip in the staff dining room has been mounted to the wall. 11/30/16. Maintenance will on a monthly basis inspect the facility to make sure all power strips are properly installed. This will be monitored on a continuous basis by the Administrator and will report any findings to the QA Committee.
C The gray extension cord will be removed from the copy machine in the Social Work Office. A receptacle will be installed for the copier 12/27/16. Maintenance will on a monthly basis inspect the facility to make sure there are no extension cords being used improperly. This will be monitored on a continuous basis by the Administrator and will report any findings to the QA Committee.
D The two power strips in the boiler room are no longer daisy-chained 12/2/16. Maintenance will on a monthly basis inspect the facility to make sure power strips are not daisy-chained. This will be monitored on a continuous basis by the Administrator and will report any findings to the QA Committee.
E The infrared bed side monitors have been unplugged from the power strips in rooms #12 and #2. 11/29/16.This will be monitored on a continuous basis by the Administrator and will report any findings to the QA Committee.

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

REGULATION: Electrical Systems - Essential Electric System Receptacles Electrical receptacles or cover plates supplied from the life safety and critical branches have a distinctive color or marking. 6.4.2.2.6, 6.5.2.2.4.2, 6.6.2.2.3.2 (NFPA 99)

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: December 2, 2016
Corrected date: January 31, 2017

Citation Details

Based on observations, interviews, and record reviews conducted during the Life Safety Code Survey, it was determined that the facility did not properly maintain electrical receptacles. Specifically, receptacles connected to the essential electrical system (generator) were not distinctively marked. This is evidenced by the following: Observations on 12/1/16 at 1:50 p.m., revealed duplex electrical outlets throughout the facility had standard cover plates that were white, gray, and silver in color. In an interview at that time, the Director of Nursing stated that only the outlets in the dining room are on generator power. She said they used to have red dots on them but they must have worn off. Further observations in the main dining room revealed five duplex electrical wall outlets with white cover plates and no distinctive markings to indicate they are connected to the emergency generator. A review of the facility loss of electrical emergency plan (section 7.38) revealed nursing is to plug suction machines into outlets served by the emergency generator, but does not specify which outlets are served by the emergency generator. The 2012 edition of NFPA 99, Health Care Facilities Code, requires the cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the life safety and critical branches shall have a distinctive color or marking so as to be readily identifiable. (10 NYCRR: 415.29(a)(2), 711.2(a)(1); 2012 NFPA 99:6.6.2.2.3.2)

Plan of Correction: ApprovedDecember 23, 2016

K917 The electrical outlets that are connected to the generator in the dining room will be marked with a red dot 12-27-16 The staff will instructed immediately and during a inservice 1-10-17. That these outlets that are marked are to be used in a power failure for those residents that may be on and oxygen concentrators and also to be used if the suction machine needs to be used. The facility as been checked and no other outlets are powered by the generator. Maintenance will check on a monthly basis to make sure the dots on the outlets are visible and secure The Administrator will monitor this and will report any findings to the QA committee.

K307 NFPA 101:HVAC

REGULATION: HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications. 18.5.2.1, 19.5.2.1, 9.2

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 2, 2016
Corrected date: January 31, 2017

Citation Details

Based on observations and an interview conducted during the Life Safety Code Survey, it was determined that for one (1983 building) of three basements, the facility did not properly maintain the heating and ventilation system. Specifically, there was no record of testing for two fire dampers in a vertical ventilation duct. This is evidenced by the following: Observations on 11/30/16 at 11:50 a.m. revealed two vertical ventilation ducts extending through the floor separation between the 1983 building basement trash collection room and the first floor. Further observations revealed two fire dampers within the ductwork held open by fusible links. When interviewed at that time, a Maintenance Staff Member stated that he was not aware the dampers were there. The Maintenance Staff Member then removed the links and one of the dampers did not fully close. There was no documentation provided by the facility to show the fire dampers had ever been tested . The 2010 edition of NFPA 80, Standard for Fire Doors and Other Opening Protectives, states: The test and inspection frequency for fire dampers shall be one year after installation then every four years, except in hospitals, where the frequency shall be every six years. (10 NYCRR: 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101:19.5.2.1, 9.2.1; 2000 NFPA 101:19.5.2.1, 9.2.1; 2012 NFPA 90A: 5.4.8.1; 2010 NFPA 80: 19.4.1.1)

Plan of Correction: ApprovedDecember 23, 2016

K521 The two fusible links to the fire dampers in the 1983 building have been removed and tested for proper operation by Maintenance 11/30/16. The fusible links will be tested by Maintenance on an annual basis.This will be monitored on a continuous basis by the Administrator and will report any findings to the QA Committee.A facility wide check will be done for similar dampers in the HVAC system with any found to be properly tested and/or repaired this will be done by Maintenance and monitored by the Administrator