Iroquois Nursing Home Inc
November 16, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.25(d)(1)(2):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 20, 2018
Corrected date: December 21, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review during the recertification survey, the facility did not ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 residents (Resident #68) reviewed for falls. Specifically, Resident #68 had a history of [REDACTED]. Additionally, the resident was observed on multiple occasions walking without shoes. Resident #68 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was independent for ambulation and required extensive assistance of one person for dressing. The resident had multiple falls including one with injury since the prior assessment. The 8/31/18 nursing progress notes documented the resident fell in the lounge while ambulating, was wearing non-skid socks, and had pain in her right hand. The Accident and Incident Investigation Process Tool and Incident Documentation Tool dated 9/4/18 documented the resident fell while walking in the hall, was wearing non-skid socks, and sustained a hematoma (collection of blood under the skin) to the back of her head. The comprehensive care plan (CCP), updated 9/4/18, documented the resident was at risk for falls related to history of falls, poor safety awareness, unsteady gait, impulsivity, wandering, and cognitive impairment. Interventions included the resident needed shoes to walk to prevent falls. The undated CNA (certified nurse aide) Assignments Summary (care instructions) documented the resident was alert, confused, ambulated independently and needed shoes to walk on the unit. The Accident and Incident Investigation Process Tool and Incident Documentation Tool dated 10/26/18 documented the resident fell while walking down the hall. She was wearing non-skid socks and reported hip pain following the fall. The incident summary documented all previous interventions were followed. The resident was observed walking without shoes wearing non-skid socks at the following times: - On 11/16/18 from 12:27 PM to 12:42 PM walking alone in the hall. - On 11/19/18 from 9:22 AM to 9:36 AM, walking alone in the hall. - On 11/19/18 from 1:53 PM to 3:08 PM, walking about the unit. The non-skid socks were not fitted to her feet and sagged around her ankles. - On 11/20/18 from 10:50 AM to 11:05 AM, walking in the hall. The non-skid socks were not fitted to her feet and sagged around her ankles. During an interview on 11/20/18 at 11:08 AM, CNA #4 stated the resident walked around during the day and wore non-skid socks provided by the facility. She stated the resident had sneakers, but did not like to wear them. She did not know of any recent falls or fall preventive measures. She would look in the CNA Assignments Summary for instruction. The CNA accessed the resident's electronic records and verified the the resident was to wear shoes when walking and non-skid socks at bedtime. She stated the resident always wore the non-skid socks and should have had her shoes on per her care instructions. On 11/22/18 at 2:35 PM, licensed practical nurse (LPN) #10 Unit Manager was interviewed. She stated the resident had a history of [REDACTED]. Interventions for safety included education to staff to keep congestion down in the halls and to ensure the resident had shoes on when walking. She stated the resident's family recently provided new shoes, they fit well, and the resident should have been wearing them while walking around the unit. The resident required assistance for dressing and getting her shoes on and she did not remove the shoes when she wore them. She had not received any reports from staff the resident refused to wear shoes or was not wearing them for any other reason. 10 NYCRR 415.12(h)(2)

Plan of Correction: ApprovedDecember 20, 2018

I. The following actions were accomplished for the residents identified in the sample:
? Resident #68 ? was re-assessed by RN DON and care plan updated to reflect that resident would benefit from wearing sneakers with ambulation ?as tolerated?. Resident noted with severe cognitive impairment. CNA's have been educated as to the importance for maintaining proper footwear with ambulation as an intervention for falls prevention and CNA's have been instructed to document and communicate via the electronic care record any refusals or displacement to unit nurse for follow up and re-evaluation of care plan.
II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
All residents have the potential to be affected by this practice:
? A full house audit has been completed to identify all residents who require specific footwear for ambulation as an intervention for falls prevention per the individualized comprehensive care plan.

? For all residents identified as requiring specific footwear with ambulation for falls prevention, the care plan, CNA instructions and falls icon have been reconciled.
III. The following system changes will be implemented to assure continued compliance with the regulation:
The facility?s guidelines ensure that:
? When a resident requires specific footwear for ambulation
1. Nursing and/or Therapy will send an OUTLOOK message to the THERAPY UPDATE group.
2. The individualized comprehensive care plan and Nursing instructions will be updated
3. The sigma care icon for the facilities ?4 P?s? (fall prevention program) will be activated/reconciled
? All staff have been educated on the new system
IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
? An audit tool has been developed to review all residents requiring specific footwear for ambulation
? QA monitoring will be conducted weekly by the DON or designee for 3 months until such time that 100% compliance is achieved.
? Findings and actions taken will be reported to the Quality Assurance Committee monthly. Frequency of on-going audits will be determined by the Committee based on audit results.
Completion Date: (MONTH) 21, (YEAR).
Responsibility: Director of Nursing

FF11 483.45(g)(h)(1)(2):LABEL/STORE DRUGS AND BIOLOGICALS

REGULATION: §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 20, 2018
Corrected date: December 21, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey, the facility did not maintain drugs and biologicals stored and labeled in accordance with currently accepted professional standards for 1 of 3 medication carts and 1 of 2 medication rooms reviewed. Specifically, the 4th floor medication cart had an expired bottle of floor stock magnesium oxide. Additionally, the 4th floor medication room had an open multi-dose vial of flu vaccine not labeled with the date opened, 13 doses of resident-specific [MEDICATION NAME] (an anti-nausea medication) were expired, and an open multi-dose vial of [MEDICATION NAME] (medication injected just under the skin to test for [MEDICAL CONDITION]) was not discarded 30 days after being opened. Findings include: The Storage of Medications policy dated ,[DATE] documented when the original manufacturer's seal of a container or vial is broken, the date opened will be attached to the container or vial and the expiration date will be 30 days. On [DATE] at 3:23 PM the 4th floor medication cart and medication room were observed with licensed practical nurse (LPN) #1. The following observations were made: - One stock bottle of magnesium oxide 400 milligram (mg) with the manufacturer's expiration date of ,[DATE], labeled as opened ,[DATE] with black permanent marker. - One open multi-dose vial of [MEDICATION NAME], manufacturer's expiration date [DATE], labeled on the outer box as opened [DATE]. - One open multi-dose vial [MEDICATION NAME] (flu vaccine), manufacturer's expiration date [DATE], without a label indicating the date opened. - 13 doses of resident-specific [MEDICATION NAME] 25 mg suppository, manufacturer's expiration date ,[DATE]. During an interview on [DATE] at 3:30 PM, LPN #1 stated she was going to notify the registered nurse (RN) Unit Manager #2 of the expired floor stock medication and dispose of it. She stated the stock clerk replaced the floor stock medications. When shown the resident-specific expired medication, she stated the resident had passed away a while ago. During an interview on [DATE] at 3:35 PM RN Unit Manager #2 stated the stock clerk from central supply stocked the medication room, and nurses put medications in the medication cart. Expectations would be to check the manufacturer's expiration date before putting medication in the cart. She stated an open multi-dose vial was good for thirty days. Her expectations for nurses would be to label vials and boxes with the date opened, and check both expiration dates before administering medication. During an interview on [DATE] at 1:41 PM stock clerk #3 stated she would check the medication expiration dates when she did the stocking and rotate the floor stock in the medication rooms based on expiration date. She stated she had nothing to do with stocking the medication carts. During an interview on [DATE] at 2:39 PM, the Director of Nursing (DON) stated her expectations for multi-dose vial medications would be nurses labeled the vial once it was opened and it was good for thirty days. She stated she would expect the nurse to check for the expiration date prior to administration of a medication. 10 NYCRR #415.18(d)

Plan of Correction: ApprovedDecember 20, 2018

I. The following actions were accomplished for the deficient practice identified in the sample:
? Fourth Floor Medication Cart audit was completed by the contracting pharmacy 11/20/18 and all expired medications identified in the course of this survey were removed and discarded per policy and practice.
II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
All residents have the potential to be affected by this practice:
? A full house audit of all medication storage areas (carts, refrigerators, cabinets, etc.) has been completed 11/20/18 to identify any and all expired, and or opened and undated medications. No further expired and or opened and undated medications were identified at the time of the audit.
III. The following system changes will be implemented to assure continuing compliance with regulations:
The facility?s guidelines ensure that:
? Medication storage area inspections are completed each shift on a daily basis by the unit nurse to identify any expired and/or opened and undated medications.
1. Unit nurse will inspect their respective medication storage areas each shift.
2. Any medications found to be expired and/or opened and undated will be discarded immediately.
3. The Unit Manager and/or designee will ensure that medication storage areas are inspected for expired and/or opened and unlabeled medications each shift and disposed of accordingly where applicable.
? All staff have been educated on the new system.
IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
? An audit tool has been developed to review all medication storage areas are inpscted each shift and expired and/or opened and undated medications are disposed of.
? QA monitoring will be conducted weekly by the Unit Manager or designee for 3 months until such time that 100% compliance is achieved.
? Findings and actions taken will be reported to the Quality Assurance Committee monthly. Frequency of on-going audits will be determined by the Committee based on audit results.
Completion Date: (MONTH) 21, (YEAR)
Responsibility: Director of Nursing

FF11 483.10(a)(1)(2)(b)(1)(2):RESIDENT RIGHTS/EXERCISE OF RIGHTS

REGULATION: §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity 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. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 20, 2018
Corrected date: December 21, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey, the facility did not ensure residents had the right to a dignified existence for 2 of 5 residents (Residents #35 and 67) reviewed for dignity. Specifically, Resident #35 was observed with a dried, pink substance on her wheelchair and Resident #67 was observed with a brown substance on her arm splint for 4 days. Additionally, the facility did not ensure residents had the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States for 2 of 2 residents (Residents #45 and 116) plus an additional 6 anonymous residents at the resident group meeting. Specifically, Residents #45 and 116 and an additional 6 residents stated they were not provided an opportunity to vote. Findings include: Dignity: 1) Resident #67 was admitted to the facility 6/5/18 and had a [DIAGNOSES REDACTED]. The 9/12/18 Minimum Data Set (MDS) assessment documented she was severely cognitively impaired, required extensive assistance with most activities of daily living (ADLs) and had limited impairment of one arm. A physician order [REDACTED]. The comprehensive care plan (CCP) effective 6/5/18 documented the resident had an alteration in mobility and transfers. Intervention included a left arm splint at all times. The certified nurse aide (CNA) care instructions, revised on 8/20/18, documented a left arm splint at all times. The resident was observed with a large, dried brown substance on her left arm splint: - On 11/15/18 at 12:29 PM in the dining room. - On 11/16/18 at 11:10 AM in her room. - On 11/19/18 at 2:00 PM in her room. - On 11/20/18 at 10:30 AM in her room. During an interview with CNA #5 on 11/20/18 at 10:05 AM, she stated she did not want to put the left arm splint on the resident today because it was dirty. She told a nurse the other day the resident needed a new splint (she could not remember the nurse's name). During an interview with Nurse Manager registered nurse (RN) #2 on 11/20/18 at 10:10 AM she stated splints came from occupational therapy (OT). They just ordered the resident a new splint because the other one was dirty. During an interview with the Therapy Program Director on 11/20/18 at 10:48 AM she stated her department had an extra supply of splints. If a splint was dirty, staff could bring the splint to them and it would be cleaned or replaced with a new splint. She was just going up to Resident #67's unit to give her a new splint. She would be doing more education with staff regarding cleaning and replacing splints. 2) Resident #35 was admitted to the facility 3/6/17 and had a [DIAGNOSES REDACTED]. The 8/25/18 MDS assessment documented she was severely cognitively impaired, and required extensive assistance with bed mobility, transfers and locomotion on the unit. The facility policy Wheelchair Cleaning dated 6/1995 included: - Wheelchairs will be cleaned weekly by the night nursing staff. - Wheelchairs can be taken to the shower rooms for cleaning. - All nursing staff shall clean off wheelchairs on a daily basis, especially after meals. The Night Shift Duties equipment washing schedule (undated) documented Resident #35's wheelchair was to be cleaned on Tuesdays (11 PM - 7 AM). The resident was observed with a dried, pink substance on the right arm and wheel of her scoot chair: - On 11/15/18 at 1:03 PM in the dining room. - On 11/16/18 at 11:11 AM in the TV lounge. - On 11/19/18 at 12:32 PM in the dining room. - On 11/20/18 at 9:37 AM in the TV lounge. During an interview with CNA #7 on 11/20/18 at 9:43 AM she stated the night shift did the wheelchair cleaning in the shower room on the unit. She sometimes saw wheelchairs in the shower room when she came on duty in the morning. She did not know if there was a schedule for wheelchair cleaning. During an interview with LPN nursing services assistant #6 (nursing support position) on 11/20/18 at 10:13 AM she stated night shift staff was supposed to clean wheelchairs weekly. There should be a cleaning schedule (she looked on the unit but could not find one). The expectation was if staff saw an unclean wheelchair they should clean it regardless of the weekly cleaning schedule. At 10:15 AM the surveyor took LPN #6 to Resident #35 in the TV lounge and showed her the dried, pink substance on the scoot chair. She stated, that should be cleaned, I will take care of it. During an interview with Director of Nursing (DON) on 11/20/18 at 2:40 PM, she stated there was a policy for wheelchair cleaning. The wheelchairs were cleaned weekly by night staff. The day to day expectation was that wheelchairs be cleaned when they were noticeably soiled. Exercise of Rights: Resident #45 was admitted [DATE] and had [DIAGNOSES REDACTED]. The 5/7/18 Minimum Data Set (MDS) assessment documented the resident had intact cognition. Resident #116 was admitted [DATE] and had [DIAGNOSES REDACTED]. The 8/30/18 MDS assessment documented the resident had intact cognition. The Resident Council meeting minutes from 5/2018 through 10/2018 documented the Ombudsman (advocate for the residents on behalf of the New York State Office for the Aging, not employed by the facility) attended each meeting, and the Director of Activities and/or the Director of Social Services attended all but the 6/2018 meeting. There was no documentation the residents' right to vote was addressed, or of the process for voting for the upcoming election in 11/2018. During an interview on 11/15/18 at 10:45 AM, the Ombudsman stated he regularly attended the monthly Resident Council meetings and had not observed anyone from the facility address the residents' right to vote. During the Resident Council meeting on 11/15/18 from 10:45 AM to 11:40 AM, 6 anonymous residents stated they were unaware of how to vote as long and short-term residents in the facility. They stated they had not been approached or advised by anyone in the facility prior to Election Day, 11/6/18. They were not made aware of any individuals who may have come to the facility to assist residents to register or vote via absentee ballot. The 6 residents stated they wanted to vote on 11/6/18. When interviewed on 11/15/18 at 11:45 AM, Resident #45 stated she wanted to vote on the recent Election Day and had not heard from anyone at the facility about how she could do so. She was unaware if she should have used the facility address as her permanent address and if she had to register to vote in the district of the nursing home. She stated she made her own healthcare decisions and signed her own admission paperwork and did not recall any discussion about registration for voting purposes or assistance for voting. When interviewed on 11/19/18 at 12:30 PM, Resident #116 stated he was usually out of state during election times. This year, he wanted to vote on 11/6/18 and no one from the facility had approached him about voting and he was unaware of what he was to do to vote. The Administrator was interviewed on 11/20/18 at 3:50 PM and stated the Director of Social Services was responsible for ensuring the residents had the right to vote. She stated the residents received information regarding voting in the admission packet, it was offered during an election year, and was reviewed at the monthly resident council meetings. On 11/20/18 at 4:15 PM, the Director of Social Work was interviewed and stated since obtaining her position in 9/2018, she had attended the resident council meetings. She had not reviewed voting with the residents at the meetings and was unaware if the former Director of Social Services had done so. She stated resident rights were reviewed at admission, and voting was not specifically addressed, as the topic is under resident rights. Residents who wished to vote could ask her for assistance with registration or absentee ballots and were not specifically approached or offered assistance. For the recent Election Day, individuals from The Board of Elections visited prior to Election Day to assist 4 or 5 residents they identified. The Director of Social Services stated the Board of Elections approached her about those residents and she went around to see them with the people from the Board. Anyone else who wanted assistance could have asked when they visited and they did not see any other residents. There was no formal announcement or posted sign and she was unaware of how residents would have been notified of the available assistance. 10NYCRR 415.3(a)(c)

Plan of Correction: ApprovedDecember 20, 2018

I.The following actions were accomplished for the residents identified in the sample:
?Resident #67 was provided with a new splint and assessed to be wearing the new, clean splint as ordered. (11/20/18).
?Resident #35 was provided with a thorough cleaning of the wheelchair and assessed to be seated in the clean wheelchair as ordered. (11/20/18).
?Resident #45 and resident # 116, each respectively were provided with education as to their individual resident rights; including their future right to vote and the facilities process and responsibility in assisting with voter registration and voting (12/7/18).
II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
?Unit staff were re-educated on the process for cleaning and replacing splints and care instructions updated to reflect changes in Plan of Care.
?No further deficient practice regarding soiled splints has been identified since 11/20/18.
?Building Supervisors and Unit staff were re-educated on the process for identifying soiled equipment and cleaning equipment (including wheelchairs) and care instructions updated to reflect changes in Plan of Care.
?No further deficient practice regarding soiled equipment (wheelchairs) has been identified since 11/20/18.
?Social Services staff were re-educated on resident rights, in particular; the resident?s right to vote together with the facilities process for facilitating voter registration and voting.
?No further deficient practice regarding resident right?s has been identified since 12/7/18.
III. The following system changes will be implemented to assure continuing compliance with regulations:
?Any Resident identified with ordered, care-planned equipment; including but not limited to splints, braces, wheelchairs, walkers, etc. will be monitored by Unit Staff throughout each shift for soiling, disrepair and general maintenance.
?The Unit Staff will clean and or replace any soiled or damaged equipment upon the immediate identification of unclean/soiled equipment.
?All direct care staff will be educated on facility practice to monitor for and replace and/or clean any unclean/soiled equipment.
?All resident?s will continue to be provided with their rights; including their right to vote when applicable upon admission to include but not limited to their right to register and participate in the voter registration process. Additionally, the facility welcome Book & Admission Packets will be augmented to highlight the availability of absentee ballots process. Absentee voting information will also be included in the new admission packet.
?All social work staff will be educated on facility practice, process and responsibility in providing residents with their rights; including and assisting with voter registration and voting.
IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
The Director of Nursing and/or Designee will track weekly audits for the day to day cleaning of all chairs/equipment issued to the Residents on all Units for 6 months until such time that 100% compliance is achieved.
?Findings and Results of audits will be reported to the Medical Services QA Committee every 6 ? 7 weeks for 6 months. Frequency of ongoing audits will be determined by the Quality Assurance Committee based on audit results.
?The Director of Nursing is responsible for continued compliance.
The Director of Social Services will track audits for the delivery and documentation of Residents Rights and; when applicable their right to vote, specifically voter registration on all units starting (MONTH) 1st, to include all in-house residents, and any new admits from then until election day.
?Findings and results of audits will be reported annually to the Special Needs QA Committee. Frequency of ongoing audits will be determined by the Quality Assurance Committee based on audit results.
?The Director of Social Services is responsible for continued compliance.
Completion Date: (MONTH) 21, (YEAR)

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2018
Corrected date: December 4, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation conducted during the recertification survey, the facility did not maintain the required 4 foot corridor width to the ends of the corridors on each of the 4 units, which primarily affected 8 of the 96 resident rooms in the facility (resident rooms #110, 122, 210, 222, 310, 322, 410, and 422). Specifically, the corridor width was restricted to approximately 4 feet in clear width between the end room on each corridor wing, and the remainder of the nursing unit. Findings include: A letter from a registered architect dated 8/7/2017 documented an FSES (Fire Safety Equivalent System) analysis was done and compliant. Due to the original construction, which included an unusual design in the corridors at the ends of each corridor wing, there was a [MEDICATION NAME] at the end of each corridor wing, which reduced the corridor width to less than four feet. On 11/15/2018, between 10:00 AM and 10:20 AM, a surveyor observed the corridor areas outside the following resident rooms: - rooms [ROOM NUMBERS]; - rooms [ROOM NUMBERS]; - rooms [ROOM NUMBERS]; and - rooms [ROOM NUMBERS]. During an interview on 11/15/2018, between 10:00 and 10:20 AM, the Maintenance Director stated the facility, related to the issue with the narrow corridor at each end of the wings, had passed the FSES. The Centers for Medicare & Medicaid Services recognizes the 2013 edition of NFPA 101A, Guide on Alternative Approaches to Life Safety, (also known as the Fire Safety Equivalent 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. 2012 NFPA 101 19.2.3.4 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedDecember 4, 2018

1) Request for continuation of the FSES.
2) Request for continuation of waiver.

K307 NFPA 101:FIRE ALARM SYSTEM - TESTING AND MAINTENANCE

REGULATION: Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: November 16, 2018
Corrected date: November 29, 2018

Citation Details

Based on record review and interview conducted during the Life Safety Code survey, the facility's fire alarm system was not tested in accordance with the requirements of National Fire Protection Association (NFPA) 72. Specifically, the semi-annual visual maintenance requirements for all initiating devices of the fire alarm system were not completed. Findings include: Review on 11/15/2018 of the facility's fire alarm system inspection reports, dated 9/5/2018 and 6/5/2018, indicated there was no documented evidence of semi-annual visual inspections for all fire alarm initiating devices. During an interview on 11/16/2018 at 3:50 PM, the Maintenance Director stated the required NFPA 72 semi-annual visual maintenance requirements for the facility's initiating devices were not completed and he was not aware that was required. 2012 NFPA 101: 19.3.4.1, 9.6.1.5 2010 NFPA 72: 14.1, 14.3.1 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedDecember 4, 2018

1) Fire alarm system was visually inspected on 11/29/2018.
2) An independent fire alarm company did a visual inspection on the remaining 50% of our fire alarm system to bring us compliant with NFPA 70 national electric code.
3) The facility Maintenance Director will conduct semi annual inspection with our fire alarm company to ensure we are compliant with NFPA 70 electric code.
4) The facility Maintenance director will report semi-annually any no compliance finding to our Facility Risk Hazards QAPI committee.
5) The facility Maintenance director will be responsible for continued compliance.

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

REGULATION: Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2018
Corrected date: December 3, 2018

Citation Details

Based on observation and interview during the Life Safety Code survey, the facility's building was not protected throughout by an approved automatic sprinkler system for 2 isolated areas (cafeteria, and laundry room hallway) in accordance with National Fire Protection Association (NFPA) 13 - Standard for Installation of Sprinkler Systems section 8.3.3.2 which states Where quick response sprinklers are installed, all sprinklers within a compartment shall be quick response unless otherwise permitted in 8.3.3.3. Specifically, the cafeteria and the laundry room hallway contained both quick response and standard response sprinkler heads. Findings include: On 11/15/2018 at 10:49 AM, a surveyor in the cafeteria observed 3 standard response heads and 5 quick response heads. On 11/15/2018 at 10:53 AM, a surveyor in the laundry room hallway observed 8 standard response heads and 2 quick response heads. During an interview on 11/15/2018 at 10:53 AM, the Maintenance Director stated he had been checking the facility to ensure there were no areas with mixed style sprinkler heads. He did not know about the mixed type sprinkler heads found in the cafeteria and the laundry room hallway. 2012 NFPA 101: 19.3.5.1, 9.7.1.1 2010 NFPA 13: 8.3.3.2 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedDecember 4, 2018

1a) On 12/3/2018 3 standard response sprinkler heads were replaced in the Employee Cafeteria.
1b) On 12/3/2018 8 standard response sprinkler heads were replaced in the Laundry Hallway.
2) The facility Maintenance Director and our sprinkler company did a complete inspection of all the sprinkler heads that were involved with our building addition to be sure we are in compliance with NFPA 13 standards for installation of the sprinkler system.
3) The facility Maintenance Director will ensure any construction or replacement of any sprinkler heads will be quick response per NFPA 13 standards.
4) The facility Maintenance Director will report any deficiencies when doing quarterly testing on our sprinkler system per NFPA 13 standards to our Facility Risk Hazards QAPI committee.
5) The facility Maintenance Director will be responsible for continued compliance.

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

REGULATION: Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2018
Corrected date: January 8, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the Life Safety Code survey, the facility did not ensure the building's automatic sprinkler system was tested in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Specifically, the dry sprinkler heads within the facility were not maintained as required. Findings include: On 11/15/2018 at 11:00 AM, a surveyor in the kitchen walk-in cooler observed a sprinkler head dated 2003. On 11/15/2018 at 11:02 AM, a surveyor in the kitchen walk-in freezer observed a sprinkler head dated 2003. Review on 11/15/2018 of the facility's sprinkler system inspection reports, dated 9/27/2017, 12/18/2017, 3/14/2018, 6/27/2018, and 9/26/2018, indicated that Are the dry sprinkler heads less then [AGE] years old? was N/A. During an interview on 11/15/2018 at 12:50 PM, the Maintenance Director stated the third party vendors had not done the [AGE] year maintenance for the dry sprinkler heads located in the kitchen walk-in cooler and walk-on freezer. 2012 NFPA 101: 19.3.5.1, 9.7.5 2011 NFPA 25, 5.1.1 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedDecember 4, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1a) The dry sprinkler head in the kitchen cooler was measured and ordered on [DATE] and will be replaced by 12/19/2018.
1b) The dry sprinkler head in the kitchen walk in freezer was measured and ordered on [DATE] and will be replaced by 12/19/2018.
2) The facility Maintenance Director and our sprinkler company did a complete inspection of the facility to be sure no other dry sprinkler heads were out of compliance per NFPA 25 standards for inspection.
3) The facility Maintenance Director will ensure during our quarterly sprinkler inspection all our sprinkler heads are inspected per NFPA 25 standards.
4) The facility Maintenance Director will report quarterly all deficiencies found during our inspection to the Facility Risks Hazards QAPI committee.

5) The facility Maintenance Director will be responsible for continued compliance.