The New Jewish Home, Manhattan
November 22, 2017 Certification Survey

Standard Health Citations

FF10 483.45(b)(2)(3)(g)(h):DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS

REGULATION: The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-- (2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and (3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. (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. (h) Storage of Drugs and Biologicals. (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. (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 22, 2017
Corrected date: January 11, 2018

Citation Details

Based on observation and staff interview the facility did not ensure that proper medications storage protocols were followed. Specifically, (1) the controlled medications were observed on the top drawer of a medication cart (not double locked). (2) The Licensed Practical Nurse (LPN) had controlled medications in her pockets. These were observed in units 5 and 7 during the Medication Storage task. Findings are: On 11/16/2017 at 10:37 AM, during the Medication Storage Task on unit 7 (Freeman Building), the following controlled medications were observed in the top drawer of the medication cart (not double locked) Morphine 15 milligrams (2 tablets), Oxycodone 2.5 mg (1 tablet), Oxycodone/Acetaminophen 7.5/525 mg (1 tablet), Lyrica 25 mg (1 tablet), Methadone 10 mg (1 tablet), Oxycodone/Hydrochloride 10 mg (1 tablet), Morphine Sulfate Extended Release 30 mg (1 tablet). All the above medications were in unit dose, kept in a clear plastic zip-lock bag. The narcotic medication box in the medication cart was also observed broken with a broken lock and could not be opened. The LPN # 2 did not maintain proper storage of controlled medications. The controlled medications were not stored in separately locked, permanently affixed compartments. An interview was conducted with LPN # 1 immediately, who stated he has been working here for the past 2 years. The LPN further stated that he floats around sometimes and realized that the narcotic box in the medication cart could not open and he put the controlled medications in the top drawer. On 11/16/17 at 10:50 AM, an interview was conducted with the Registered Nurse Supervisor # 1 who stated he supervises units 6 and 7 and was unaware that the narcotic box was broken. The RN supervisor # 1 further stated that controlled medications are to stored in a double locked compartment. On 11/16/2017 at 11:22 AM , during the Medication Storage Task on unit 5 (Freeman Building) LPN #2 stated that there were no controlled medications in the double locked box in the medication room because the medications had been taken out this morning. The LPN then removed a clear zip-lock bag from her pocket. The following medications were found in the clear zip-lock bag: Oxycodone 2.5 mg (7 tablets), Oxycodone/Acetaminophen 5/325 (2 tablets), Oxycodone 5 mg (5 tablets ) Hydrocortisone 4 mg , (1 tablet) Oxycodone/Hydrochloride 10 mg (1 tablet), and Clonazepam 0.5 mg (1 tablet). The LPN # 2 did not maintain proper storage of controlled medications. The controlled medications were not stored in separately locked, permanently affixed compartments. An interview was conducted with LPN # 2 who stated that she has been working here for about 9 years. She also stated that she was aware that the medications were supposed to be double locked. She further stated that she was about to administer medication to a resident and her laptop went dead so she put back the medication in her pocket. The narcotic box on this unit is working fine but I took the medication out because I doing medication pass. On 11/16/17 at 12 noon, an interview was conducted with the RN supervisor # 2 who stated that the narcotic box in the unit is in good working condition and could not explain why the LPN # 2 put medications in her pocket. The facility policy Storage of Pharmaceuticals dated 5/2006 documented the following scheduled controlled medications are stored separately in a double locked cabinet in the nursing station. 415.18(d)

Plan of Correction: ApprovedDecember 12, 2017

I. Plan for Cited Area
? Both LPN?s involved with the improper storage of narcotics were re-educated on the policy for proper Nursing Storage of Pharmaceuticals (11/16/17)
? Plant Operations was notified of the defective lock on the medication carts narcotic drawer on(NAME)Six and(NAME)Seven, and the locks were immediately repaired. (11/16/17)
II. Plan to identify Potentially affected residents
? Plant Operations completed a full inspection of all 21 medication carts and confirmed that all of the double lock narcotic drawers on the medication carts were fully functional. (11/16/17)
III. Measures and Systems
? The Director of Nursing and Director of Pharmacy reviewed the existing facility policy for Nursing Storage of Pharmaceuticals and confirmed that it meets all of the elements of the regulations for storage of narcotics. (11/27/17)
? The Clinical Educator will re-educate all of the licensed nurses on the existing policy. (11/16/17-12/4/17)
IV. Plan for Follow Up/Monitoring
? On a daily basis for one month the Director of Pharmacy/Designee will complete 100% audits of all medication carts to confirm proper storage of narcotics (12/11/17 for one month).
? Thereafter on a weekly basis for a period of three months, the Director of Pharmacy/Designee will complete 100% audits to confirm proper storage of narcotics.
? The findings of the audits will be reported to the Director of Nursing
? The Director of Nursing will report the findings to the QAPI Committee on a monthly basis.
? The QAPI Committee will review the findings and determine ongoing auditing.
I. Responsible for Compliance
? The Director of Nursing will be responsible for maintaining compliance

FF10 483.80(a)(1)(2)(4)(e)(f):INFECTION CONTROL, PREVENT SPREAD, LINENS

REGULATION: (a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: (1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards (facility assessment implementation is Phase 2); (2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv) When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi) The hand hygiene procedures to be followed by staff involved in direct resident contact. (4) A system for recording incidents identified under the facility?s IPCP and the corrective actions taken by the facility. (e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. (f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 22, 2017
Corrected date: January 11, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility did not ensure that infection control practices were followed. Specifically, during the wound care observation, the Registered Nurse (RN) was not observed performing hand hygiene and changing gloves appropriately during a wound care treatment observation. This was evident for 1 of 2 residents observed for Pressure Ulcers. (Resident # 828). The findings are: Resident #828 is an [AGE] year old admitted to the facility on [DATE]. Active [DIAGNOSES REDACTED]. On 11/21/2017 at 10:28 AM, the resident was observed in the room, lying in bed, alert and awake. The resident was able to make appropriate conversation, and stated that wound was present on admission. The resident was also observed with a Foley Catheter. The Minimum Data Set (MDS) 3.0 Admission assessment dated [DATE] documented the following: Cognitive status is intact, no mood and behavioral problems identified. The MDS further documented that the resident required total assistance with dressing, toilet use, bathing and personal hygiene. The resident is incontinent of bowel and also with an Indwelling Foley Catheter. Nursing Admission assessment dated [DATE] documented that the resident was admitted with Unstageable Pressure Ulcer to the Sacrum. Treatment order dated 11/2017 documented the following: Irrigate wound with normal saline, apply Santyl to wound bed, pack wound with gauze, and cover with dry dressing. On 11/22/17 at 10:37 AM, a wound care observation was conducted for Resident # 828 and the following were observed: during the dressing change preparation, the Registered Nurse (RN) assisted the Certified Nurse Aide to (CNA) remove a soiled diaper from the resident. The RN removed the soiled gloves, donned clean gloves but did not perform hand hygiene. The RN then removed the soiled dressing, discarded the soiled dressing, removed the soiled gloves and did not perform hand hygiene before donning clean gloves. The RN did not perform hand hygiene after removing soiled gloves and before donning clean gloves. On 11/22/2017 at 11:01 AM, an interview was conducted with the wound nurse who stated that she has been working as an RN at the facility for over 7 years. The RN stated that the nurse must wash hands before and after removing gloves. The RN further stated that she was probably preoccupied with the wound appearance because the wound bed looked different from the last time she was there. On 11/22/2017 at 11:24 AM, an interview was conducted with the Infection Control nurse who is also a Clinical Educator, who stated that everyone receives infection control training periodically. We have trained staff on infection control practices, especially hand washing. Every nurse has also been cleared and deemed competent to perform wound care without any problems. Everyone is expected to be competent on the infection control protocol. The nurse educator could not explain why the wound nurse did not wash her hands The facility policy and procedure Hand Hygiene revised 9/2017 documented the following: Wash hands with soap and water and must use gloves in the following situations-if hands are visibly soiled, after removing or before donning gloves. 415.19 (b)(4)

Plan of Correction: ApprovedDecember 13, 2017

I. Plan for Affected Resident
? The Clinical Educator provided one on one re-in servicing to the RN involved in the resident?s care on the proper technique on hand hygiene and changing gloves properly during wound care. (11/22/17)
? The RN performed a return demonstration to the Clinical Educator on the proper technique for hand hygiene and changing gloves properly while performing wound care (11/24/17)
? The IDCP team met to confirm that the comprehensive care plan for the cited resident addressed all identified needs. (11/27/17)
II. Plan to identify potentially affected residents
? The Clinical Educator/Designee completed observations of 100% of all licensed nurses on the performance of hand hygiene and the proper changing of gloves during wound care and determined that there were no other potentially affected residents. (12/14/17)
III. Measures and System
? The Director of Nursing reviewed the existing policy for hand hygiene and the proper changing of gloves during wound care and determined it meets the requirements for infection control as outlined by the CDC. 11/27/17
? The Clinical Educator/Designee will re-educate all appropriate licensed nurses on the exiting policy for hand hygiene and proper changing of gloves during wound care. (12/24/17)
IV. Plan for Follow up/Monitoring
? On a monthly basis for the next three months, the Clinical Educator/Designee will observe 100% of all of the licensed nurses in the performance of hand hygiene during wound care. (12/14/17 and ongoing)
? Thereafter, on a monthly basis for the next three months, the Clinical Educator/Designee will observe 50% of all licensed nurses in performance of hand hygiene during wound care. (12/14/17 and ongoing)
? The findings of the audits will be reported to the Director of Nursing for review and remediation as necessary.
? The Director of Nursing will report the findings of the audits to the QAPI Committee on a monthly basis.
? Based on the results of the audits, the QAPI committee will recommend the frequency of the ongoing audits
V. Responsible for Compliance
? The Director of Nursing will be responsible for maintaining compliance

FF10 483.75(g)(1)(i)-(iii)(2)(i)(ii)(h)(i):QAA COMMITTEE-MEMBERS/MEET QUARTERLY/PLANS

REGULATION: (g) Quality assessment and assurance. (1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of: (i) The director of nursing services; (ii) The Medical Director or his/her designee; (iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and (g)(2) The quality assessment and assurance committee must : (i) Meet at least quarterly and as needed to coordinate and evaluate activities such as identifying issues with respect to which quality assessment and assurance activities are necessary; and (ii) Develop and implement appropriate plans of action to correct identified quality deficiencies; (h) Disclosure of information. A State or the Secretary may not require disclosure of the records of such committee except in so far as such disclosure is related to the compliance of such committee with the requirements of this section. (i) Sanctions. Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 22, 2017
Corrected date: January 11, 2018

Citation Details

Based on observation, record review and interview, the facility did not ensure the Quality Assurance committee (QA) effectively identified quality deficiencies and implemented plans of correction for identified deficiencies, including monitoring the effect of revised action plans. Specifically, the corrective plans of actions that were implemented were not effective, and as a result, repeated deficiencies identified during the recertification survey of 11/22/17. (Reference F-441) Findings are: Please refer to findings at F 441 of the recertification survey of 11/22/17: Based on observation and staff interview, the facility did not ensure that infection control practices were followed. Specifically, during the wound care observation, the Registered Nurse (RN) was not observed performing hand hygiene and changing gloves appropriately during a wound care treatment observation. The Plan of Correction (P(NAME)) submitted by the facility with a completion date of 9/16/16 documented the following: The Assistant Director of Nursing (ADON) re-in serviced the LPN's and will observe all licensed nursing on performance of hand hygiene during wound care. The Director of Nursing will present reports to QAPI committee meetings monthly and ongoing and there would be an Audit tool used from 10/26/16 and ongoing. The provider's plan of correction was not effective. Based on interview of staff and residents and observations by the State Agency the facility did not provide evidence that their corrective action plan has been effectively implemented and monitored. The ADON provided Hand washing attendance record dated 8/25/16 and 9/15/16. In-service Attendance records for nursing staff documented check marks under the headings VAD/Central and Blood Glucose however no check marks were observed under the heading Wound Care. The ADON was unable to provide additional documents verifying that QA reports and audits had been ongoing. On 11/22/17 at 1:39 PM, an interview conducted with the QAPI Director who stated I am only in this position for the past 4 months. We hired Educator but also only here since (MONTH) of (YEAR). On 11/22/17 at 1:49 PM, an interview was conducted with the ADON who stated that the immediate plan of correction was education and quarterly in-services were conducted as needed. I believe the nurses are confident in their skills and know they should wash hands when moving from dirty items to clean ones. 415.27 (a-c)

Plan of Correction: ApprovedDecember 12, 2017

I. Plan for Affected Resident
? No residents were affected.
II. Plan to Identify Potentially Affected
? The Director of QAPI and the VP of Clinical Excellence reviewed the (YEAR) Plan of Correction and affirmed that the facility was in compliance with the elements of the follow up and monitoring of each of the cited deficiencies.
? Completion Date: 12/14/17
III. Measure and Systems
? The Director of Quality Assurance and Performance Improvement and the Assistant Director of Nursing reviewed the policy for Quality Assurance and Performance Improvement to ensure the committee effectively identifies deficiencies and implemented plans of correction for identified deficiencies, including monitoring the effect of revised action plans.
? The Administrator and Vice President for Clinical Excellence reviewed the existing Quality Assurance and Performance Improvement Program and determined that it meets all of the elements of the regulations.
? Respective Department Heads with responsibilities related to Quality Assurance and Performance Improvement were re-educated on the Quality Assurance and Performance Improvement Program.
? Completion Date: 12/8/17
IV. Monitoring
? On a monthly basis the Quality Assurance and Performance Committee will meet and review all of the ongoing audits for the plan of correction and determine compliance with the stated plan.
V. Responsible for Compliance
? The Administrator is responsible for maintaining compliance.

E3BP 402.9(b)(2):RESPONSIBILITIES OF PROVIDERS; REQUIRED NOTIF

REGULATION: Section 402.9 Responsibilities of Providers; Required Notifications. ...... (b) Notifications. A provider must immediately, but within no later than 30 calendar days after the event, notify the Department, and document such notification occurred, when: ...... (2) any employee who was subject to, and underwent, a criminal history record check in accordance with this Part is no longer employed by the provider.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 22, 2017
Corrected date: January 11, 2018

Citation Details

Based on record review and staff interview, the facility did not submit the DOH (Department of Health) 105 Termination form for an employee who was not hired by the facility within the required 30 day time period. This was evident for 1 of 1 prospective employees reviewed for Criminal History Record Check (CHRC) with Negative Determination letters. Findings are: The Prospective employee completed a job application on 4/19/17 for a Food Service Worker position. The facility record documented that the prospective employee underwent the Criminal History Record Check process on 6/01/17. The record also documented that the facility received a Final Denial-a Letter to Provider letter dated 8/11/17. The facility CHRC Roster documented that the employee was terminated in the system on 10/25/17, which was not within the required 30 calendar day time period. There was no documented evidence that the facility submitted form #105 to the CHRC within 30 days after receiving a negative determination letter. On 11/20/2017 at 2:44 PM, an interview was conducted with the Director of Human Resources (HR), the facility Authorized Person, who stated that once an offer is made to individual, they will sign a consent form for back ground check. We don't hire an individual until they are cleared from the CHRC. This employee was never hired. The HR director further stated that employees with negative determination letters are supposed to be terminated within 30 days but could not explain why this potential employee was not terminated. The facility policy on Criminal History Record Check (CHRC) dated 1/19/17 documented that, in an event that a prospective or employee leave the company, the Human Resources department shall complete and electronically submit a CHRC form 105 as applicable within 30 days of the day of termination.

Plan of Correction: ApprovedDecember 12, 2017

I. Plan for Affected Resident
? No residents were affected.
? The Senior Director of Human Resources immediately confirmed that the individual identified in question was terminated from Criminal History Record Check (CHRC) website.
? Completion Date: 11/22/17
II. Plan to Identify Potentially Affected
? The Senior Director of Human Resources reviewed all database entries for terminated staff and determined that there were no other potentially affected individuals.
? Completion Date: 11/28/17
III. Measure and Systems
? The Senior Director of Human Resources reviewed the facility policy for Criminal History Record Check (CHRC and Criminal Background Check System) to ensure that the facility is responsible to submit the Department of Health 105 Termination form for an employee who was not hired by the facility within the required 30 day time period, including the monitoring of this process.
? The policy was updated to reflect that audits will be conducted on a monthly basis.
? The Director of Human Resources? policy review determined that it meets all of the elements of the regulations.
? Respective authorized persons in Human Resources with responsibilities related to termination of an employee within CHRC were re-educated on the updated policy.
? Completion Date: 12/5/17
IV. Monitoring
? The Director of Human Resources/designee will conduct monthly audits for six (6) months to ensure all those required to be terminated from the CHRC website are terminated within 30 days of termination.
? Results of the audit will be reported to the monthly Quality Assurance and Performance Improvement meeting beginning (MONTH) (YEAR) through (MONTH) (YEAR).
? Based on the results of the audits the QAPI committee will recommend frequency of ongoing auditing.
V. Responsible for Compliance
? The Senior Director of Human Resources for maintaining compliance.

Standard Life Safety Code Citations

K307 NFPA 101:CORRIDORS - CONSTRUCTION OF WALLS

REGULATION: Corridors - Construction of Walls 2012 EXISTING Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames. If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area. 19.3.6.2, 19.3.6.2.7

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: November 22, 2017
Corrected date: February 1, 2018

Citation Details

The following requirement has been waived. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the condition under which the waivers have been granted have not changed. Please indicate if the facility wishes the waiver to be continued or provide a plan of correction. K362 S/S=B Television Rooms/Dining rooms on patient floors in the Sutro Pavilion are not separated from the Corridor. 2012 NFPA 101: 19.3.6.2, 19.3.6.2.7 42 CFR 483.70 (a) NYCRR 711.2(a)(1)

Plan of Correction: ApprovedDecember 22, 2017

This requirement has been previously waived and this facility is requesting continuation of the waiver. The conditions under which the waiver was granted have not changed

K307 NFPA 101:DISCHARGE FROM EXITS

REGULATION: Discharge from Exits Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface. 18.2.7, 19.2.7

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: November 22, 2017
Corrected date: February 1, 2018

Citation Details

The following requirement has been waived. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the condition under which the waivers have been granted have not changed. Please indicate if the facility wishes the waiver to be continued or provide a plan of correction. K 271 S/S=B Where accumulation of snow or ice is likely because of the climate, the exterior exit access shall be protected by a roof. The access to the alternate exit on the 8th floor of the(NAME)Building is via an unprotected roof area. 2012 NFPA101: 19.2.7, S&C 05-38 42 CFR 483.70 (a) NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedDecember 22, 2017

This requirement has been previously waived and this facility is requesting continuation of the waiver. The conditions under which the waiver was granted have not changed

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: November 22, 2017
Corrected date: February 1, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, during the recertification survey, electrical cords were noted utilized instead of fixed wiring, and that the appropriate Underwriter's Laboratory (UL) listed power strips were not being utilized for a resident room in the(NAME)building (1of 3 buildings). The findings are: During the Life Safety Code survey conducted on 11/20/17, 11/21/17, and 11/22/17 between 9:00am and 2:00pm the following was noted: 1. Electrical extension cords were noted in use instead of fixed wiring in the research Suite of the penthouse and in resident room [ROOM NUMBER] of the 7th floor. 2 The power strip that was utilized in resident room [ROOM NUMBER] was not appropriately UL listed for use in resident care areas. The power strip was noted with a UL 3462 listing. In an interview on 11/21/17 at approximately 9:45am, the Assistant Director of Plant Operations stated the approved UL listed power-strip would be provided in the room. He took notes of the extension cords in use. 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 711.2(a)(1) 2012NFPA101: NYCRR 711.2(a) 10 NYCRR 415.29

Plan of Correction: ApprovedDecember 22, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Plan for cited area:
The outlet with exposed wires was repaired and properly re-fed power (12/22/17)
The extension cord in the penthouse and resident room [ROOM NUMBER] were removed (11/22/17)
The power strip in 749 was replaced with a power strip rated UL 1363 (11/22/17)
Plan for other potentially affected areas
The Associate Director of Plant Operations/designee conducted a facility wide survey to ensure that all power strips in use were the appropriate UL listed 1363 (12/22/17)
Measures and Systems
The Associate Director of Plant Operations has provided education to all of the engineering staff on the approved power strips (12/22/17)
Plan for Follow up and Monitoring
During weekly Environment of Care rounds the inspection team shall inspect all power strip to confirm that they are in compliance with the regulation 12/22/17 and ongoing)

K307 NFPA 101:ELECTRICAL SYSTEMS - OTHER

REGULATION: Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 6 (NFPA 99)

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: November 22, 2017
Corrected date: February 1, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 99: 6.3.2.1 Electrical Installation. Installation shall be in accordance with NFPA 70, National Electrical Code. 2011 NFPA 70: 110.27 Guarding of Live Parts. (A) Live Parts Guarded Against Accidental Contact. Except as elsewhere required or permitted by this Code, live parts of electrical equipment operating at 50 volts or more shall be guarded against accidental contact by approved enclosures or by any of the following means: (1) By location in a room, vault, or similar enclosure that is accessible only to qualified persons. Based on observation and staff interview, the facility's electrical system was not in compliance with NFPA 70 in that electrical panels were unlocked in resident accessible areas. This was noted on six of seven floors in the(NAME)building. The findings are: On 11/21/17 between 8:55am- 11:50am during the recertification survey, electrical panels were noted unlocked in resident accessible areas. Examples include but are not limited to: 1) The electrical panel in the corridor adjacent to resident room [ROOM NUMBER] 2) The electrical panel in the corridor adjacent to resident room [ROOM NUMBER] 3) The electrical panel in the corridor adjacent to resident room [ROOM NUMBER] 4) The electrical panel in the corridor adjacent to resident room [ROOM NUMBER] 5) The electrical panel in the corridor adjacent to resident room [ROOM NUMBER] 6) The electrical panel in the corridor adjacent to resident room [ROOM NUMBER] In an interview on 11/21/17 at approximately 11:20am, the Corporate Director of Support Services stated that they would do a house-wide check. 2012 NFPA 99: 6.3.2.1 2011 NFPA 70: 110.27 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedDecember 22, 2017

I. Plan for cited area
? The Engineering staff provided locks to the following electrical panels that are in resident accessible areas:(NAME)7,(NAME)6,(NAME)5,(NAME)4,(NAME)3 and(NAME)2 (12/22/17).
V. Plan to identify other potentially affected areas:
? The Associate Director of Plant Operations surveyed all facility electrical panels and confirmed that they were all locked in accordance with the regulation (12/22/17)
VI. Measures and systems
? The Associate Director of Plant Operations educated all the maintenance staff on the regulation to ensure the locking of electrical panels that are in resident accessible areas. (12/22/17)
VII. Plan for Follow up/Monitoring
? During weekly Environment of Care rounds the inspection team shall inspect electrical panels in resident accessible areas to confirm that they are locked. (12/22/17 and ongoing)
II. Responsible for Compliance
? The Associate Director of Plant Operations will be responsible for maintaining compliance

K307 NFPA 101:GAS AND VACUUM PIPED SYSTEMS - WARNING SYSTEM

REGULATION: Gas and Vacuum Piped Systems - Warning Systems All master, area, and local alarm systems used for medical gas and vacuum systems comply with appropriate Category warning system requirements, as applicable. 5.1.9, 5.2.9, 5.3.6.2.2 (NFPA 99)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 22, 2017
Corrected date: February 1, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 99: 5.1.9.1 General. All master, area, and local alarm systems used for medical gas and vacuum systems shall include the following: (1) Separate visual indicators for each condition monitored, except as permitted in 5.1.9.5.2 for local alarms that are displayed on master alarm panels (2) Visual indicators that remain in alarm until the situation that has caused the alarm is resolved (3) Cancelable audible indication of each alarm condition that produces a sound with a minimum level of 80 dBAat 0.92 m (3 ft) (4) Means to visually indicate a lamp or LED failure (5) Visual and audible indication that the communication with an alarm-initiating device is disconnected (6) Labeling of each indicator, indicating the condition monitored (7) Labeling of each alarm panel for its area of surveillance (8) Reinitiation of the audible signal if another alarm condition occurs while the audible alarm is silenced (9) Power for master, area alarms, sensors, and switches from the life safety branch of the emergency electrical system as described in Chapter 6 (10) Power for local alarms, dew point sensors, and carbon monoxide sensors permitted to be from the same essential electrical branch as is used to power the air compressor system (11) Where used for communications, wiring from switches or sensors that is supervised or protected as required by 517.30(C)(3) of NFPA 70, National Electrical Code, for life safety and critical branches circuits in which protection is any of the following types: (a) Conduit (b) Free air (c) Wire (d) Cable tray (e) Raceways (12) Communication devices that do not use electrical wiring for signal transmission will be supervised such that failure of communication shall initiate an alarm. (13) Assurance by the responsible authority of the facility that the labeling of alarms, where room numbers or designations are used, is accurate and up-to-date (14) Provisions for automatic restart after a power loss of 10 seconds (e.g., during generator start-up) without giving false signals or requiring manual reset (15) Alarm switches/sensors installed so as to be removable Based on observation, staff interview and documentation review, the medical gas alarm panel on the 2nd floor of the Sutro building was observed to be non-functional. The findings are: On 11/20/17 during documentation review at approximately 2:10pm during the recertification survey, it was noted that the medical gas alarm panel on the 2nd floor of the Sutro building was non-functional. The inspection report indicated There are 1 medical gas alarm panels that are inoperative and need emergency repair. On 11/21/17 at approximately 12:21pm, the medical gas alarm panel in the vicinity of resident room [ROOM NUMBER] was observed to be non-functional. In an interview on 11/20/17 at approximately 2:10pm, the Associate Director of Plant Operations stated that the medical gas alarm panel was not repaired and that he will have the company repair it immediately. 2012 NFPA 99: 5.1.9.1 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedDecember 22, 2017

Plan for Cited Area
Major Medical Hospital Services replaced the necessary parts for the Sutro Two oxygen valve and completed the necessary repairs. (12/20/17)
Plan to identify other potentially affected areas:
There is only one oxygen alarm panel in the sutro building
Measures and Systems
The annual inspection of the alarm paneled is scheduled with the certified company. Any noted deficiencies during the inspection will be corrected at the time of inspection.
Plan for follow up and monitoring
The results of the annual inspection will be reported at the environment of care committee
The Associate Director of Plant Operations will be responsible for ongoing compliance

K307 NFPA 101:GAS EQUIPMENT - CYLINDER AND CONTAINER STORAG

REGULATION: Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING." Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 22, 2017
Corrected date: February 1, 2018

Citation Details

2012 NFPA 99: 11.3.4 Signs 2012 NFPA 99: 11.3.4.1 A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure. 2012 NFPA 99: 11.3.4.2 The sign shall include the following wording as a minimum: CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING 2012 NFPA99: 11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders. 2012 NFPA99: 11.6.5.3 Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner. Based on observation and staff interview, oxygen storage rooms lacked required signage. This was noted on six of seven floors in the(NAME)building. The findings are: On 11/21/17 between 8:55am- 11:50am during the recertification survey, it was noted that in the(NAME)building, the required signage was not provided for the oxygen storage rooms on floors 2-7. The provided signage indicated only Oxygen Storage. Additionally, the oxygen storage rooms lacked signage within the room to indicate the empty cylinders. In an interview on 11/21/17 at approximately 11:34am, the Corporate Director of Support Services stated that they would put up the appropriate signs. 2012 NFPA 99: 11.3.4, 11.3.4.1, 11.3.4.2, 11.6.5.2, 11.6.5.3 10NYCRR 711.2(a)(1)2012 NFPA 99: 11.3.4 Signs 2012 NFPA 99: 11.3.4.1 A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure. 2012 NFPA 99: 11.3.4.2 The sign shall include the following wording as a minimum: CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING 2012 NFPA99: 11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders. 2012 NFPA99: 11.6.5.3 Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner. Based on observation and staff interview, oxygen storage rooms lacked required signage. This was noted on six of seven floors in the(NAME)building. The findings are: On 11/21/17 between 8:55am- 11:50am during the recertification survey, it was noted that in the(NAME)building, the required signage was not provided for the oxygen storage rooms on floors 2-7. The provided signage indicated only Oxygen Storage. Additionally, the oxygen storage rooms lacked signage within the room to indicate the empty cylinders. In an interview on 11/21/17 at approximately 11:34am, the Corporate Director of Support Services stated that they would put up the appropriate signs. 2012 NFPA 99: 11.3.4, 11.3.4.1, 11.3.4.2, 11.6.5.2, 11.6.5.3 10NYCRR 711.2(a)(1)2012 NFPA 99: 11.3.4 Signs 2012 NFPA 99: 11.3.4.1 A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure. 2012 NFPA 99: 11.3.4.2 The sign shall include the following wording as a minimum: CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING 2012 NFPA99: 11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders. 2012 NFPA99: 11.6.5.3 Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner. Based on observation and staff interview, oxygen storage rooms lacked required signage. This was noted on two of four floors in the Sutro building. The findings are: On 11/21/17 between 11:51am- 12:55pm during the recertification survey, the following was noted for oxygen storage rooms in the Sutro building: 1) The clean utility room on the 4th floor was observed being used for oxygen storage. There was no sign provided to indicate oxygen storage within the room. Additionally, signage was lacking within the room to indicate the empty cylinders 2) The oxygen holding room on the 1st floor was not provided with a sign to indicate oxygen storage within the room. Additionally, signage was lacking within the room to indicate the empty cylinders In an interview on 11/21/17 at approximately 12:35pm, the Corporate Director of Support Services stated that they would put up the appropriate signs. 2012 NFPA 99: 11.3.4, 11.3.4.1, 11.3.4.2, 11.6.5.2, 11.6.5.3 10NYCRR 711.2(a)(1)2012 NFPA 99: 11.3.4 Signs 2012 NFPA 99: 11.3.4.1 A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure. 2012 NFPA 99: 11.3.4.2 The sign shall include the following wording as a minimum: CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING 2012 NFPA99: 11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders. 2012 NFPA99: 11.6.5.3 Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner. Based on observation and staff interview, oxygen storage rooms lacked required signage. This was noted on two of four floors in the Sutro building. The findings are: On 11/21/17 between 11:51am- 12:55pm during the recertification survey, the following was noted for oxygen storage rooms in the Sutro building: 1) The clean utility room on the 4th floor was observed being used for oxygen storage. There was no sign provided to indicate oxygen storage within the room. Additionally, signage was lacking within the room to indicate the empty cylinders 2) The oxygen holding room on the 1st floor was not provided with a sign to indicate oxygen storage within the room. Additionally, signage was lacking within the room to indicate the empty cylinders In an interview on 11/21/17 at approximately 12:35pm, the Corporate Director of Support Services stated that they would put up the appropriate signs. 2012 NFPA 99: 11.3.4, 11.3.4.1, 11.3.4.2, 11.6.5.2, 11.6.5.3 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedDecember 22, 2017

Plan for cited area
Proper laminated signs have been installed to all the oxygen storage rooms in the sutro building. The signs state:
CAUTION: oxidizing gas(es) stored within NO SMOKING
Signs indicated full and empty were appropriately placed in the oxygen storage room.
Plan to identify other potentially affected areas.
The Associate Director of Plant Operations conducted a survey of all oxygen storage room to confirm that the signs were all appropriately placed
Measures and Systems
The Associate Director of Plant Operations reviewed the existing policy for oxygen storage and confirmed that it addressed the requirements for the appropriate signage and the segregation of full and empty tanks.
The Associate Director of Plant Operations/designee will in-service all the appropriate clinical staff on the appropriate storage of oxygen.
Plan for Follow up/Monitoring
On a daily basis the Associate Director of Plant Operations/designee will inspect the oxygen storage rooms to confirm appropriate signage and segregation of full and empty tanks.
The results of these inspections will be reported to the E(NAME) committee
The Associate Director of Plant Operations will be responsible for maintaining compliance

K307 NFPA 101:INTERIOR WALL AND CEILING FINISH

REGULATION: Interior Wall and Ceiling Finish 2012 EXISTING Interior wall and ceiling finishes, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and have a flame spread rating of Class A or Class B. The reduction in class of interior finish for a sprinkler system as prescribed in 10.2.8.1 is permitted. 10.2, 19.3.3.1, 19.3.3.2 Indicate flame spread rating(s). _____________________

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 22, 2017
Corrected date: February 1, 2018

Citation Details

Based on observation and staff interview, during the recertification survey, the flame spread rating for wall coverings in the egress corridor could not be determined for the 1st floor of the(NAME)building (1of 3 buildings). The findings are: During the Life Safety Code survey conducted on 11/21/17 of the 1st floor of the(NAME)building between 12:30pm to 1:30pm, it was noted that the egress corridor at the elevator lobby and near the staff rest room, contained wall carpet/covering that went from the floor level up to the ceiling. In an interview on the same day at approximately 12:30pm, the Assistant Director of Plant Operations stated that there must be a rating specification on file for the wall covering and that it would be provided. There was no documentation provided to the surveyors by the exit date of the survey. 2012 NFPA 101: 10.2.8.1, 10.2, 19.3.3.1, 19.3.3.2 2010 NFPA 13: 8.15.3.2.2 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedDecember 22, 2017

!. Plan for Cited Area:
The wall carpeting cited has been treated by an approved flame retardant on (MONTH) 6, (YEAR).
2. Plant to identify other potentially affected areas
A survey was conducted by the Associate Director of Plant Operations in all three resident care buildings and confirmed that there were no additional affected areas.
3. Measures and systems
The Associate Director of Plant Operations has contracted an approved vendor to perform fire retardant applications on an annual basis.
4. Plan for follow up and Monitoring
The Associate Director of Plant Operations/designee will present the documentation of the annual fire retardant application at the environment of care meeting
5. Ongoing COmpliance
The Associate Director of Plant Operations will be responsible for maintaining compliance

K307 NFPA 101:MEANS OF EGRESS - GENERAL

REGULATION: Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 22, 2017
Corrected date: February 1, 2018

Citation Details

2012 NFPA 101: 19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11. 2012 NFPA 101: 7.1.10.2.3 Mirrors shall not be placed on exit door leaves. Mirrors shall not be placed in or adjacent to any exit in such a manner as to confuse the direction of egress. Based on observation and staff interview, mirrors were observed on exit stair doors in the(NAME)building. This was noted for stairs on two of seven floors. The findings are: On 11/21/17 between 8:55am- 11:50am during the recertification survey, mirrors were observed on exit stair doors in the(NAME)building. Examples are: 1)(NAME)7 (7th floor)- Stair H 2)(NAME)6 (6th floor)- Stairs H & I In an interview on 11/21/17 at approximately 10:35am, the Corporate Director of Support Services stated that he will have the mirrors removed. 2012 NFPA 101: 19.2.1, 7.1.10.2.3 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedDecember 22, 2017

I. Plan for Cited Area
? The mirror on(NAME)6 Stairs H & I was removed (11/22/17)
? The mirror on(NAME)7 Stair H was removed (11/22/17)
II. Plan to identify Potentially affected areas
? The Associate Director of Plant Operations conducted an inspection of all exit doors and confirmed that all exit doors were free of mirrors (12/13/17)
III. Measures and Systems
? The Associate Director of Plant Operations provided education to all of the maintenance staff on the regulation that all means of egress must be maintained free of all obstructions (12/22/217)
IV. Plan for Follow Up/Monitoring
? During weekly Environment of Care rounds the inspection team shall inspect all egress doors to confirm that they are in compliance with the regulation to be maintained free of all obstructions (12/22/17 and ongoing)
I. Responsible for Compliance
? The Associate Director of Plant Operations will be responsible for maintaining compliance
I.

K307 NFPA 101:MEANS OF EGRESS REQUIREMENTS - OTHER

REGULATION: Means of Egress Requirements - Other List in the REMARKS section any LSC Section 18.2 and 19.2 Means of Egress requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. 18.2, 19.2

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 22, 2017
Corrected date: February 1, 2018

Citation Details

2012 NFPA 101: 7.7.3.4* Stairs and ramps that continue more than one-half story beyond the level of discharge shall be provided with an approved means to prevent or dissuade occupants from traveling past the level of discharge during emergency building evacuation. This requirement is not met as evidenced by: Based on observation and staff interview, during the recertification survey, the facility did not ensure that an emergency exit stairwell that travels more than one-half story beyond the level of exit discharge was interrupted at the level of exit discharge. This was noted in the Sutro building (1 of 3 buildings). The findings are: During the Life Safety Code survey conducted of the Sutro basement on 11/21/17 at approximately 11:30am, it was noted that emergency exit Stairwell 1 that connects the floors, travels one story below grade to the basement and was not provided with the means to prevent or dissuade occupants from traveling past the level of exit discharge. There were no signs or barriers provided to warn occupants. In an interview at this time, the Assistant Director of Plant Operations stated that the approved signs or barriers would be installed for the stairwell and every other stairwell with this issue. 2012NFPA101: 7.7 NYCRR 711.2(a) 10 NYCRR 415.29

Plan of Correction: ApprovedDecember 22, 2017

I. Plan for Cited Area
? The proper directional signage was installed in the cited area (11/22/17)
Plan to identify Potentially affected areas:
? The Associate Director of Plant Operations conducted an inspection of all signage and confirmed that there are no other potentially affected areas. (12/13/17)
II. Measures and Systems
? The Associate Director of Plant Operations will review the changes to the facility to confirm compliance with applicable regulations as it relates to egress paths. (12/22/217)
III. Plan for Follow Up/Monitoring
? During weekly Environment of Care rounds the inspection team shall inspect signage to egress doors to confirm that they are in compliance with the regulation 12/22/17 and ongoing)
I. Responsible for Compliance
? The Associate Director of Plant Operations will be responsible for maintaining compliance
I.

K307 NFPA 101:PORTABLE FIRE EXTINGUISHERS

REGULATION: Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 22, 2017
Corrected date: February 1, 2018

Citation Details

Based on observation, staff interview, and documentation review during the recertification survey, the facility did not demonstrate evidence of the monthly portable fire extinguisher inspection. This was noted on all floors inspected in the(NAME)Building (1of 3 buildings). The findings include: During the Life Safety Code survey conducted on 11/20/17, 11/21/17, and 11/22/17 between 9:00am and 2:00pm, the inspection tags on portable fire extinguishers within the(NAME)building were noted with annual service dates of (MONTH) and (MONTH) of (YEAR). There were no monthly visual inspections indicated for the portable fire extinguishers after these dates. In an interview on 11/21/17, at approximately 9:15am, the Assistant Director of Plant Operations stated that the security department is responsible for inspecting the portable fire extinguishers. In an interview at the exit conference on 11/22/17 at approximately 2:30pm, the Administrator and the Assistant Director of Plant Operations stated that the records of the monthly fire extinguishers would be provided if available to the Regional Office via email. No records were provided to the surveyor by the time of writing up this deficiency. 2012 NFPA 101: 19.3.5.12 2010 NFPA 10: 6.1.3.8, Table 8.3.1 NYCRR 711.2(a) 10 NYCRR 415.29

Plan of Correction: ApprovedDecember 22, 2017

Plan for Cited Area
Alert Fire Control Company completed the fire extinguisher and fire hose inspection. They have also replaced all fire extinguishers that were due for maintenance 12/22/17.
Plan to Identify Other Potentially Affected Area
All extinguishers replaced, there are no other potentially affected areas.
Measures and Systems
The Director of Security reviewed the policy for Fire Extinguishers and Monthly inspection and confirmed that it meets the regulations for inspection and maintenance of fire extinguishers.
The Director of Security provided education to all of the security officers on the policy for inspection and maintenance of fire extinguishers.
Plan for follow up and monitoring
On a monthly basis the Director of Security will conduct a full house audit to confirm compliance with the monthly inspections of fire extinguishers.
The results of the audits will be presented to the monthly Environment of Care Committee

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 22, 2017
Corrected date: February 1, 2018

Citation Details

2012 NFPA 101: 19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. 2012 NFPA 101: 9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following: (1) NFPA 13, Standard for the Installation of Sprinkler Systems (2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes (3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height 2010 NFPA 13: 8.15.10.1 Unless the requirements of 8.15.10.3 are met, sprinkler protection shall be required in electrical equipment rooms. 2010 NFPA 13: 8.15.10.3 Sprinklers shall not be required in electrical equipment rooms where all of the following conditions are met: (1) The room is dedicated to electrical equipment only. (2) Only dry-type electrical equipment is used. (3) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations. (4) No combustible storage is permitted to be stored in the room. Based on observation and staff interview, the facility was not protected throughout by an approved, supervised sprinkler system in that areas within the building were not provided with automatic sprinkler coverage and did not meet the requirements to omit sprinklers. This was noted in the transfer switch room in the(NAME)building basement. The findings are: On 11/21/17 at approximately 9:00am during the recertification survey, the transfer switch room in the(NAME)building basement was observed lacking sprinkler coverage. The room did not meet the requirements for omission of sprinklers in that the facility could not verify that a 2-hour fire-rated enclosure was provided. Two of two doors to the room were provided with transfer grilles and lacked fire-rated labels. In an interview on 11/21/17 at approximately 9:00am, the Engineering Supervisor stated that an outside vendor recently certified all the fire-rated doors in the buildings and they can provide the documentation. There was no documentation provided to the surveyors by the exit date. 2012 NFPA 101: 19.3.5.1, 9.7.1.1 2010 NFPA 13: 8.15.10.1, 8.15.10.3 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. 2012 NFPA 101: 9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following: (1) NFPA 13, Standard for the Installation of Sprinkler Systems (2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes (3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height 2010 NFPA 13: 8.15.10.1 Unless the requirements of 8.15.10.3 are met, sprinkler protection shall be required in electrical equipment rooms. 2010 NFPA 13: 8.15.10.3 Sprinklers shall not be required in electrical equipment rooms where all of the following conditions are met: (1) The room is dedicated to electrical equipment only. (2) Only dry-type electrical equipment is used. (3) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations. (4) No combustible storage is permitted to be stored in the room. Based on observation and staff interview, the facility was not protected throughout by an approved, supervised sprinkler system in that areas within the building were not provided with automatic sprinkler coverage and did not meet the requirements to omit sprinklers. This was noted in the transfer switch room in the(NAME)building basement. The findings are: On 11/21/17 at approximately 9:00am during the recertification survey, the transfer switch room in the(NAME)building basement was observed lacking sprinkler coverage. The room did not meet the requirements for omission of sprinklers in that the facility could not verify that a 2-hour fire-rated enclosure was provided. Two of two doors to the room were provided with transfer grilles and lacked fire-rated labels. In an interview on 11/21/17 at approximately 9:00am, the Engineering Supervisor stated that an outside vendor recently certified all the fire-rated doors in the buildings and they can provide the documentation. There was no documentation provided to the surveyors by the exit date. 2012 NFPA 101: 19.3.5.1, 9.7.1.1 2010 NFPA 13: 8.15.10.1, 8.15.10.3 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. 2012 NFPA 101: 9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following: (1) NFPA 13, Standard for the Installation of Sprinkler Systems (2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes (3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height 2010 NFPA 13: 8.15.10.1 Unless the requirements of 8.15.10.3 are met, sprinkler protection shall be required in electrical equipment rooms. 2010 NFPA 13: 8.15.10.3 Sprinklers shall not be required in electrical equipment rooms where all of the following conditions are met: (1) The room is dedicated to electrical equipment only. (2) Only dry-type electrical equipment is used. (3) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations. (4) No combustible storage is permitted to be stored in the room. Based on observation and staff interview, the facility was not protected throughout by an approved, supervised sprinkler system in that areas within the building were not provided with automatic sprinkler coverage and did not meet the requirements to omit sprinklers. This was noted in the transfer switch room in the(NAME)building basement. The findings are: On 11/21/17 at approximately 9:00am during the recertification survey, the transfer switch room in the(NAME)building basement was observed lacking sprinkler coverage. The room did not meet the requirements for omission of sprinklers in that the facility could not verify that a 2-hour fire-rated enclosure was provided. Two of two doors to the room were provided with transfer grilles and lacked fire-rated labels. In an interview on 11/21/17 at approximately 9:00am, the Engineering Supervisor stated that an outside vendor recently certified all the fire-rated doors in the buildings and they can provide the documentation. There was no documentation provided to the surveyors by the exit date. 2012 NFPA 101: 19.3.5.1, 9.7.1.1 2010 NFPA 13: 8.15.10.1, 8.15.10.3 10NYCRR 711.2(a)(1)Based on observation and staff interview, during the recertification survey, the facility was not protected throughout by an approved, supervised automatic sprinkler system in that areas within the building were not provided with automatic sprinkler coverage or met the exception for sprinkler protection. Reference is made to the main electrical room of the Friedman building (1 of 3 buildings) that was noted with a non-conforming door. The findings are: During the Life Safety Code survey conducted in the Friedman building basement on 11/22/17 at approximately 11:45am, it was noted that the main electrical room was not provided with sprinkler protection. One of two doors to the room was noted to be 45 minutes rated. For the electrical room to meet the exemption of sprinkler coverage, the doors to the room must be 90 minutes rated. In an interview at this time, the Assistant Director of Plant Operations stated that the door would be changed to a 90 minute or more fire rated door. 2012 NFPA 101: 19.3.5.1, 9.7.1.1 2010 NFPA 13: 8.15.3.2.2 10NYCRR 711.2(a)(1)Based on observation and staff interview, during the recertification survey, the facility was not protected throughout by an approved, supervised automatic sprinkler system in that areas within the building were not provided with automatic sprinkler coverage or met the exception for sprinkler protection. Reference is made to the main electrical room of the Friedman building (1 of 3 buildings) that was noted with a non-conforming door. The findings are: During the Life Safety Code survey conducted in the Friedman building basement on 11/22/17 at approximately 11:45am, it was noted that the main electrical room was not provided with sprinkler protection. One of two doors to the room was noted to be 45 minutes rated. For the electrical room to meet the exemption of sprinkler coverage, the doors to the room must be 90 minutes rated. In an interview at this time, the Assistant Director of Plant Operations stated that the door would be changed to a 90 minute or more fire rated door. 2012 NFPA 101: 19.3.5.1, 9.7.1.1 2010 NFPA 13: 8.15.3.2.2 10NYCRR 711.2(a)(1)Based on observation and staff interview, during the recertification survey, the facility was not protected throughout by an approved, supervised automatic sprinkler system in that areas within the building were not provided with automatic sprinkler coverage or met the exception for sprinkler protection. Reference is made to the main electrical room of the Friedman building (1 of 3 buildings) that was noted with a non-conforming door. The findings are: During the Life Safety Code survey conducted in the Friedman building basement on 11/22/17 at approximately 11:45am, it was noted that the main electrical room was not provided with sprinkler protection. One of two doors to the room was noted to be 45 minutes rated. For the electrical room to meet the exemption of sprinkler coverage, the doors to the room must be 90 minutes rated. In an interview at this time, the Assistant Director of Plant Operations stated that the door would be changed to a 90 minute or more fire rated door. 2012 NFPA 101: 19.3.5.1, 9.7.1.1 2010 NFPA 13: 8.15.3.2.2 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. Based on observation and staff interview, the mechanical room on the Sutro building roof was not provided with sprinkler coverage. The findings are: On 11/21/17 at approximately 12:50pm during the recertification survey, the mechanical room on the Sutro building roof was not provided with sprinkler coverage. In an interview on 11/21/17 at approximately 12:50pm, the Engineering Supervisor stated that they will call the sprinkler company. 2012 NFPA 101: 19.3.5.1 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. Based on observation and staff interview, the mechanical room on the Sutro building roof was not provided with sprinkler coverage. The findings are: On 11/21/17 at approximately 12:50pm during the recertification survey, the mechanical room on the Sutro building roof was not provided with sprinkler coverage. In an interview on 11/21/17 at approximately 12:50pm, the Engineering Supervisor stated that they will call the sprinkler company. 2012 NFPA 101: 19.3.5.1 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. Based on observation and staff interview, the mechanical room on the Sutro building roof was not provided with sprinkler coverage. The findings are: On 11/21/17 at approximately 12:50pm during the recertification survey, the mechanical room on the Sutro building roof was not provided with sprinkler coverage. In an interview on 11/21/17 at approximately 12:50pm, the Engineering Supervisor stated that they will call the sprinkler company. 2012 NFPA 101: 19.3.5.1 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedJanuary 3, 2018

Plan for Cited Area
? An inspection of the cited doors was conducted by Brand Services to provide the required 2 hour rated doors. The doors have been purchased and installation will commence on 12/31/17 with completion 2/1/18.
II. Plan to identify potentially affected residents
? An inspection of all facility doors was conducted on 10/16/17 by a certified vendor and all doors with deficiencies were noted in the report. Brand Services has been engage to order and install fully compliant fire rated doors
III. Measures and System
? The Associate Director of Plant Operations will coordinate with the vendor for the installation of fire rated doors (2/1/18)
IV. Plan for Follow up/Monitoring
? The installation of the fire rated doors will be documented and presented to the Environment of Care meeting to confirm compliance with the regulation (2/1/18)
V. Responsible for Compliance
? The Associate Director of Plant Operations will be responsible for maintaining 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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 22, 2017
Corrected date: February 1, 2018

Citation Details

2012 NFPA 101: 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested , and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 2011 NFPA 25: 4.1.8.1 A permanently marked metal or rigid plastic information sign shall be placed at the system control riser supplying an antifreeze loop, dry system, preaction system, or auxiliary system control valve. Based on observation and staff interview, the facility did not ensure that automatic sprinkler systems are inspected, tested , and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems in that control valves of the sprinkler were provided with information signs that did not indicate the areas they served. This was noted on three of seven floors in the(NAME)building. The findings are: On 11/21/17 between 8:55am- 11:50am during the recertification survey, it was noted that control valves of the sprinkler system were provided with information signs that did not indicate the areas they served. This was noted within Stair H in the(NAME)building, including but not limited to floors 2, 4 & 6. In an interview on 11/21/17 at approximately 11:17am, the Corporate Director of Support Services stated that they will add the areas served to the signs. 2012 NFPA 101: 9.7.5 2011 NFPA 25: 4.1.8.1 10NYCRR 711.2(a)(1)2012 NFPA 101: 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested , and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 2011 NFPA 25: 4.1.8.1 A permanently marked metal or rigid plastic information sign shall be placed at the system control riser supplying an antifreeze loop, dry system, preaction system, or auxiliary system control valve. Based on observation and staff interview, the facility did not ensure that automatic sprinkler systems are inspected, tested , and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems in that control valves of the sprinkler were provided with information signs that did not indicate the areas they served. This was noted on three of seven floors in the(NAME)building. The findings are: On 11/21/17 between 8:55am- 11:50am during the recertification survey, it was noted that control valves of the sprinkler system were provided with information signs that did not indicate the areas they served. This was noted within Stair H in the(NAME)building, including but not limited to floors 2, 4 & 6. In an interview on 11/21/17 at approximately 11:17am, the Corporate Director of Support Services stated that they will add the areas served to the signs. 2012 NFPA 101: 9.7.5 2011 NFPA 25: 4.1.8.1 10NYCRR 711.2(a)(1)Based on observation and staff interview during the recertification survey, the facility did not maintain their sprinkler system in accordance with 2011 NFPA 25 Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems in the Friedman building (1of 3 buildings). Reference is made to the following: 1. Lack of records indicating an annual fire pump test. 2. Lack of records indicating a five-year sprinkler system check valve inspection. 3. Lack of records indicating a five-year sprinkler system pressure gauge maintenance. 4. Lack of spare sprinklers of the sidewall type. 5. Painted/missing sprinkler caps and foreign materials on sprinkler heads. The findings are: During the Life Safety Code survey conducted on 11/20/17, 11/21/17, and 11/22/17 between 9:00am and 2:00pm, the following was noted: 1. The facility did not provide records for the following: - The most recent annual fire pump test. - The last sprinkler five-year check valve inspection. - The five-year sprinkler pressure gauge maintenance (calibration or change). 2. There was no spare supply of the side wall type sprinkler heads kept onsite. Side wall type sprinkler heads were noted in use within the facility. 3. Sprinkler heads/caps were noted with foreign materials. Examples included but are not limited to the following: Friedman Building: - 7th and 5th floors: pieces of plastic stuck to the sprinkler head within the linen chute. - 3rd floor: two recessed sprinklers were missing caps in the dining room. - 1st floor board room/conference room was noted with six painted sprinkler caps. The Assistant Director of Plant Operations was taking notes during the tours and stated that all the issues would be addressed. In a separate interview at the exit conference on 11/22/17 at approximately 2:30pm, both the Administrator and the Assistant Director of Plant Operations stated that the missing records would be sent to the Regional Office via email. No records were provided to the surveyor by the time of writing up this deficiency. 2012 NFPA 101: 9.7.5, 9.7.7, 9.7.8 10NYCRR 711.2(a)(1) 10 NYCRR 415.29Based on observation and staff interview during the recertification survey, the facility did not maintain their sprinkler system in accordance with 2011 NFPA 25 Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems in the Friedman building (1of 3 buildings). Reference is made to the following: 1. Lack of records indicating an annual fire pump test. 2. Lack of records indicating a five-year sprinkler system check valve inspection. 3. Lack of records indicating a five-year sprinkler system pressure gauge maintenance. 4. Lack of spare sprinklers of the sidewall type. 5. Painted/missing sprinkler caps and foreign materials on sprinkler heads. The findings are: During the Life Safety Code survey conducted on 11/20/17, 11/21/17, and 11/22/17 between 9:00am and 2:00pm, the following was noted: 1. The facility did not provide records for the following: - The most recent annual fire pump test. - The last sprinkler five-year check valve inspection. - The five-year sprinkler pressure gauge maintenance (calibration or change). 2. There was no spare supply of the side wall type sprinkler heads kept onsite. Side wall type sprinkler heads were noted in use within the facility. 3. Sprinkler heads/caps were noted with foreign materials. Examples included but are not limited to the following: Friedman Building: - 7th and 5th floors: pieces of plastic stuck to the sprinkler head within the linen chute. - 3rd floor: two recessed sprinklers were missing caps in the dining room. - 1st floor board room/conference room was noted with six painted sprinkler caps. The Assistant Director of Plant Operations was taking notes during the tours and stated that all the issues would be addressed. In a separate interview at the exit conference on 11/22/17 at approximately 2:30pm, both the Administrator and the Assistant Director of Plant Operations stated that the missing records would be sent to the Regional Office via email. No records were provided to the surveyor by the time of writing up this deficiency. 2012 NFPA 101: 9.7.5, 9.7.7, 9.7.8 10NYCRR 711.2(a)(1) 10 NYCRR 415.29

Plan of Correction: ApprovedDecember 22, 2017

1. Plan for cited area
The 5 year sprinkler system inspection was completed on 6/24/17
Reem Plumbing and Heating was contacted on 11/21/17 to perform a flow and pressure test of the fire pump in the presence of the New York City Fire Department Inspector which was completed on 12/15/17
Sidewall sprinkler heads have been ordered and caps installed
The plastic on the sprinkler head in the linen chute on the 7th and 5th floor was removed
The sprinkler caps were replaced in the 3rd floor dining room
The painted sprinkler caps in the board room will be fixed
2. Plan to identify other potentially affected areas
The Associate Director of Plant Operations surveyed all sprinkler heads in the(NAME)building to confirm that the caps were installed
The Associate Director of Plant Operations installed metal covers to protect the linen chute sprinkler heads
3. Measures and Systems
The Associate Director of Plant Operations provided education to the engineering staff on the maintenance of the sprinkler system.
4. Plan for Follow up and Monitoring
During weekly E(NAME) rounds the inspection team will conduct an assessment of sprinkler heads to confirm compliance with the regulations
The results of the annual fire pump testing will be presented to the Environment of Care committee to confirm compliance with the regulations
5. The Associate Director of Plant Operations will be responsible for maintaining compliance