Suffolk Center for Rehabilitation and Nursing
July 12, 2017 Certification Survey

Standard Health Citations

FF10 483.20(g)-(j):ASSESSMENT ACCURACY/COORDINATION/CERTIFIED

REGULATION: (g) Accuracy of Assessments. The assessment must accurately reflect the resident?s status. (h) Coordination A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals. (i) Certification (1) A registered nurse must sign and certify that the assessment is completed. (2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment. (j) Penalty for Falsification (1) Under Medicare and Medicaid, an individual who willfully and knowingly- (i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or (ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment. (2) Clinical disagreement does not constitute a material and false statement.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 12, 2017
Corrected date: September 8, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview during the Recertification survey, the facility did not ensure the Minimum Data Set (MDS) Assessments accurately reflected each resident's current status. This was evident for two of thirty four Stage 2 sampled residents. Specifically, 1) Resident # 34 had an incorrect [DIAGNOSES REDACTED].#141 was incorrectly coded to have a decline in bladder function from frequently incontinent to always incontinent. The findings are: 1) Resident # 34 has [DIAGNOSES REDACTED]. A Psychiatric Consultation dated 11/8/16 documented that the [DIAGNOSES REDACTED]. The Psychiatrist documented that the resident had no history of mental illness and no signs of [MEDICAL CONDITION]. The Annual MDS assessment dated [DATE] documented [MEDICAL CONDITION] as an Active Diagnosis. The MDS documented that there were no signs and symptoms of [MEDICAL CONDITION] and no Behaviors exhibited. The Comprehensive Care Plan (CCP) for [MEDICAL CONDITION] Drug use last updated on 1/18/17 documented that the resident had [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] continued to document [MEDICAL CONDITION] as an Active Diagnosis. The MDS Assessment documented that the resident had Severely Impaired Cognition. There were no behaviors documented on the MDS during the Assessment period. A Psychiatric Consultation dated 4/13/17 documented that the resident had [DIAGNOSES REDACTED]. The MDS Coordinator/Registered Nurse (RN) was interviewed on 07/11/2017 at 2:39 PM and stated that the RN who competed the MDS Assessments for Resident #34 was no longer working at the facility. The RN stated that because the resident was receiving an antipsychotic medication when the MDS was completed the [MEDICAL CONDITION] Disorder [DIAGNOSES REDACTED]. The RN stated that the change in the [DIAGNOSES REDACTED]. The resident's Physician at the time of the change of the [DIAGNOSES REDACTED]. The resident's current Physician/Medical Doctor (MD) was interviewed on 07/12/2017 at 11:06 AM. The MD stated that when she became the resident's attending physician the [DIAGNOSES REDACTED]. The MD stated that the primary [DIAGNOSES REDACTED].
2) Resident #141 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. An Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) Score as 12 which indicated moderate cognitive impairment. The resident required extensive assist of two staff members for toileting, was not on a Urinary Toileting Program and was frequently incontinent of urine. A Quarterly MDS assessment dated [DATE] documented the resident's BIMS Score as 11 which indicated moderate cognitive impairment. The resident required extensive assist of two staff members for toileting, was not on a Urinary Toileting Program and was always incontinent of urine. A Comprehensive Care Plan (CCP) dated 1/25/17, and revised 2/7/17, documented the resident was frequently incontinent of bladder. The goal was that the resident will remain free from skin breakdown due to incontinence and brief use through the review date of 8/24/17. Interventions included to keep skin clean and dry, and to provide peri-care after each incontinent episode. There was no documented evidence in the CCP that the resident had a change in bladder function, from frequently incontinent of urine to always incontinent of urine. A review of the Certified Nursing Assistant (CNA) Intervention/Task for urinary continence dated 1/26/17 to 1/31/17 documented the resident has frequent episodes of urinary incontinence each shift. A review of the CNA Intervention/Task for urinary continence dated 4/25/17 to 4/30/17 documented the resident had frequent episodes of urinary incontinence each shift. An interview was conducted on 7/10/17 at 1:59 PM with the day shift CNA. The CNA stated that she recalled the resident and knew the resident pretty well. The CNA stated that the resident was incontinent of bladder and that she changed the resident two to three times per shift. The CNA stated that at times the resident was a heavy wetter and other times when she checked the resident she was dry. The CNA stated that she did not see any change in the resident's urinary pattern. An interview was conducted on 7/10/17 at 2:12 PM with the Licensed Practical Nurse (LPN). The LPN stated that the resident was frequently incontinent of urine and that the resident was checked and changed every two hours as needed. The LPN stated that the resident was a Hoyer transfer with assist of two staff members and that the resident has always been frequently incontinent of urine. The LPN stated that no change in the resident's bladder function was reported to her. An interview was conducted on 7/10/17 at 2: 45 PM with the MDS Registered Nurse (RN). The RN stated that the resident's urinary function was coded in the MDS based on what was documented in the CNA Intervention/Task for urinary continence. A review of the CNA Task documentation was conducted by the RN during the interview and revealed there was no change in the resident's urinary status. The resident continued to be frequently incontinent of urine. The RN stated that the MDS was incorrectly coded and that a correction will be done. 415.11(b)

Plan of Correction: ApprovedJuly 26, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F278
1. The MDS dated [DATE] for resident #34 was modified and the resident?s medical record immediately updated. The MDS dated for 5/1/17 for resident #141 was modified immediately.
2. (a) All residents with recommended [DIAGNOSES REDACTED].
(b) The medical record of all incontinent residents have the potential to be affected by this practice.
A full house audit was conducted of all psychiatric consults done within the last 30 days and no discrepancies were noted. The MDS, care plan and certified nursing assistant record of all incontinent residents has/will been reviewed to ensure accuracy of documentation.
3. The facility psychiatric visits weekly and effective immediately copies of the psychiatric consults will be given to the MDS RN to ensure addition or removal of recommended changes to the medical [DIAGNOSES REDACTED]. A ?Psychiatric [DIAGNOSES REDACTED]. The RN Unit Managers will utilize this audit tool weekly to ensure that all recommended additions or removal of psychiatric [DIAGNOSES REDACTED]. During weekly care plan meetings, the MDS coordinator will audit all MDS?s, care plans and certified nursing records for consistent documentation of incontinency utilizing the ?MDS, Care Plan and CNAAR Audit Tool?. All MDS personnel, Unit managers, nurses and members of the care plan team will be in-serviced.
4. 100% of the audits will be reviewed weekly for one month then 50% therefore after. The results of the audits will be forwarded to the QA committee for review on regularly scheduled meetings.
5. DNS/Designee

FF10 483.10(i)(2):HOUSEKEEPING & MAINTENANCE SERVICES

REGULATION: (i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 12, 2017
Corrected date: September 8, 2017

Citation Details

Based on observations and staff interview during the Recertification Survey, the facility did not ensure the resident's environment was being properly maintained in a sanitary and orderly manner. Specifically, there were multiple rooms with furnishings in disrepair, and areas in need of cleaning and painting. In addition, there was an basement exterior door observed with a large gap creating a portal of entry for insects and pests. The findings are: 1) During the initial tour on 7/7/17 at 10:45 AM of the second floor nursing unit the following was observed: Room 221 The Radiator inside the bathroom was rusted and in need of replacement. There were two stained ceiling tiles above the bed nearest to the door. The radiator cover is falling off behind the resident's bed. The three drawer dresser was in disrepair; the surface was chipped. Room 226 The wall opposite the bed was badly marked and marred and in need of painting. The bedroom door was in disrepair. The three drawer dresser was in disrepair; the surface was chipped. Room 228 The night stand was in disrepair with multiple areas that were chipped. 2) During an observation on 7/7/17 at 11:14 AM, the following was noted on the first floor unit: Room 126 W The radiator cover was in disrepair. Room 202 The bathroom door was in disrepair; there were multiple large areas that were chipped, and the door was in need of replacement. 3) During observations on 7/11/17 at 10:00 AM and 7/12/17 at 8:00 AM, the following was noted: The sliding exterior basement door leading to the patio had a large gap of approximately 2 inches creating a portal of entry for insects and other pests. The gap was along an entire side and the bottom of the door. An interview was conducted with the Director of Maintenance on 7/12/17 at 2:00 PM. He stated that the areas identified will be addressed and that multiple bathroom doors have already been replaced. 415.5(h)(2)

Plan of Correction: ApprovedJuly 26, 2017

1.(a)Rm 221: The facility Maintenance staff replaced the ceiling tiles, fixed and painted the radiator covers and also replaced the dresser.
(b) Rm 226: The maintenance staff painted the walls and also replaced the dresser.
(c) Rm 228: The maintenance staff fixed and refinished the night stand
(d) Rm 126: The maintenance staff fixed and repainted the radiator cover.
(e) Rm 202 The maintenance staff replaced the bathroom door.
(f) Patio Door: The maintenance staff adjusted the sliding door leading out to the patio and added a door sweep.
2. All residents were have potential to be affected by this deficiency. The facility Maintenance Director and Director of Nursing or (designee) will conduct interdisciplinary rounds of all resident rooms and corridors and address all dressers, walls and radiator covers.
3. The facility Maintenance Director and Director of Nursing/Designee will conduct monthly Interdisciplinary Environmental Rounds to assure maintenance or repairs and address any new issues. Results of these rounds will be documented on new Building Inpection Audit Tool and necessary repairs entered into Maintenance Unit Log for repair.
4. Results of Interdisciplinary Environmental Rounds will be reported to QAPI at regularly scheduled meetings, or at minimum quarterly.
5. DES/Designee

FF10 483.25(g)(1)(3):MAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE

REGULATION: (g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident?s comprehensive assessment, the facility must ensure that a resident- (1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident?s clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; (3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 12, 2017
Corrected date: September 8, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff and resident interview during the Recertification Survey, the facility did not ensure that all resident's therapeutic diets were being implemented when ordered by the Physician. This was identified for one of 34 Stage 2 sampled residents. Specifically, Resident #169 did not receive the physician's orders [REDACTED]. The finding is: Resident # 169 has a [DIAGNOSES REDACTED]. An Admission Minimum Data Set Assessment ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13 indicating that the resident's cognition was intact. The Initial Nutrition assessment dated [DATE] documented recommendations to discontinue the low fat diet and to add the NCS diet due to a [DIAGNOSES REDACTED]. Review of the current physician's orders [REDACTED]. Observation of the resident's lunch meal on 7/11/17 at 12:00 PM revealed that the meal ticket documented the following diet: Low Fat Low Sodium Regular (consistency). The lunch meal ticket did not include No Concentrated Sweets (NCS) as part of the therapeutic intervention. The meal ticket documented two packets of regular sugar, not sugar substitute, to be included on the lunch meal tray. Further observation on 7/11/17 at 12:15 PM revealed that two empty individual sugar packets were noted on the resident's dresser. An interview was conducted with the Registered Dietitian (RD) on 7/11/17 at 11:50 AM. The RD stated that the resident's Diabetes is diet controlled and that the NCS diet is being used for that reason. She further explained that the resident is not on Diabetic medications. The RD also stated that the resident's initial Nutrition assessment dated [DATE] recommended to discontinue the low fat diet and add the NCS secondary to a [DIAGNOSES REDACTED]. An interview with the alert and lucid resident on 7/11/17 at 12:15 PM revealed that he is slightly Diabetic and is controlled by diet. An interview was conducted with the Food Service Director on 7/11/17 at 1:30 PM. He stated that he checks the communication book for diet changes on a daily basis and throughout the day and must have missed the change. 415.12(i)(1)

Plan of Correction: ApprovedJuly 26, 2017

F325?
1. The affected resident #169 meal ticket and next meal serving were corrected to reflect the MD diabetic diet order.
2. All diabetic residents have the potential to be affected by this practice. A full house audit was conducted of all diabetic residents to ensure the MD prescribed diabetic order matches the meal ticket dietary computer system. All MD orders and diet tickets match.
3. All diet changes are conveyed to the food service director by the dietician via means of a communication book. A new ?Diet Change Audit Tool? will be implemented and completed by the dietician/food service director to ensure all recommended diet changes are updated in the dietary computer system to match the MD prescribed diet. The audit will be done 100% weekly x4 weeks then 25% monthly thereafter.
4. The results of the ?Diet Change Audit? will be forwarded to the QA committee at scheduled meetings and/or quarterly for review.
6. Registered Dietician/Food Service Director/Designee.

FF10 483.25(e)(1)-(3):NO CATHETER, PREVENT UTI, RESTORE BLADDER

REGULATION: (e) Incontinence. (1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. (2)For a resident with urinary incontinence, based on the resident?s comprehensive assessment, the facility must ensure that- (i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident?s clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident?s clinical condition demonstrates that catheterization is necessary and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. (3) For a resident with fecal incontinence, based on the resident?s comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 12, 2017
Corrected date: September 8, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification survey the facility did not ensure that the residents Indwelling Foley Catheter (F/C) was assessed for removal or that the medical record had documentation of a medical justification for the continued use. This was evident for one of one resident reviewed for F/C use. Specifically, Resident #164 had an Indwelling F/C with no documented evidence for a medical or clinical justification for continued use. The finding is: Resident #164 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) Score of 15 indicating cognition intact. The MDS also documented the resident had a Foley catheter. A Hospital Discharge Summary dated 5/30/17 documented that the resident had a F/C and that the resident was going to a subacute facility. The Hospital Discharge Summary also documented that the subacute facility was to re-assess the F/C and a initiate a trial void. The physician's orders [REDACTED]. A Comprehensive Care Plan (CCP) dated 6/12/17 titled Indwelling Foley Catheter related to [MEDICAL CONDITION] was developed. The CCP documented to monitor for a Urinary Tract Infection. A Orthopedic Consult dated 6/23/17 documented a recommendation to discontinue the resident's F/C to help prevent infection. A Physician's Progress Note dated 7/5/17 documented that the resident has a F/C with no documented [DIAGNOSES REDACTED]. The Treatment Administration Record (TAR) dated (MONTH) (YEAR) documented the resident had an indwelling F/C for a [DIAGNOSES REDACTED]. There was no documented evidence in the medical record that an assessment for removal was completed, that a medical or clinical justification for the continued use was documented, or that the hospital recommendations for a trial void was initiated. An interview was held on 7/11/17 at 11:50 AM with the Registered Nurse (RN) Unit Manager. The RN reviewed the medical record and stated that the [DIAGNOSES REDACTED]. The RN also stated that there was no documented evidence of a medical justification for the continued use of the F/C or that a trail void was initiated. An interview was held with the resident's Physician on 7/11/17 at 1:30 PM. The Physician stated that the F/C was for a [DIAGNOSES REDACTED]. The Physician also stated that she was not made aware of the orthopedic recommendations to discontinue the F/C. 415.12(d)(2)

Plan of Correction: ApprovedSeptember 7, 2017

1. Affected resident is no longer in the facility.
2. All residents utilizing a urinary catheter have the potential to be affected by this practice. All residents with urinary catheters were re-assessed for medical justification for continued usage.
3. All residents admitted with or have a newly placed urinary catheter must have clear documentation from the MD on the next comprehensive assessment for need for continued usage. The Urinary Catheter policy was reviewed. A new ?Urinary Catheter Audit Tool? will be implemented to ensure that all Urinary catheters have the appropriate medical diagnosis. All Medical and Nursing staff were re-inserviced on ensuring appropriate medical justification for catheter usage.
4. The new ?Urinary Catheter Audit Tool? will be completed monthly by the Unit Managers for all residents with Urinary catheters and as needed for new admits with catheters or newly placed catheters. The results of the audits will be forwarded to the QA committee at scheduled meetings or quarterly.
5. Director of Nursing/Designee.

FF10 483.21(b)(3)(ii):SERVICES BY QUALIFIED PERSONS/PER CARE PLAN

REGULATION: (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (ii) Be provided by qualified persons in accordance with each resident's written plan of care.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 12, 2017
Corrected date: September 8, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during the Recertification Survey, the facility did not ensure that services were provided by qualified persons in accordance with each resident's written plan of care. This was evident for 1 of 1 resident reviewed for Accidents. Specifically, Resident #161 was observed not wearing a smoking apron as determined to be required in a Smoking Evaluation. The finding is: Resident #161 was admitted on [DATE] has [DIAGNOSES REDACTED]. An Admission Minimum Data Set (MDS) assessment dated [DATE] documented that the resident was independent in daily decision making with a Brief Interview for Mental Status (BIMS) Score of 15. The MDS documented that the resident uses tobacco (Section J1300). A Smoking Evaluation dated 6/12/17 documented that the resident required Supervision and a Smoking Apron. An updated Smokers List dated 7/4/17 documented that Resident #161 was to wear a Smoking Apron. A Smoking Log dated 7/10/17 documented that Resident #161 was to wear a Smoking Apron. A current Comprehensive Care Plan for Smoking was reviewed on 7/10/17 and documented that the resident was to wear a Smoking Apron. On 7/10/17 at 11:30 AM, Resident #161 was observed smoking a cigarette outside on the patio during a smoking session. The resident was observed not wearing a Smoking Apron. The Recreation Aide (RA) monitoring the smoking session was interviewed on 7/10/17 at 11:30 AM. The RA stated that he follows the Smokers List to see who needs the apron and he is responsible for putting the apron on. The RA further stated that Resident #161 used to wear the apron but for the past few weeks has not needed it. The Director of Recreational Activities was interviewed on 7/10/17 at 12:06 PM and stated that the RA should look at the Smokers List and follow it. The Director further stated that Resident #161 should wear a Smoking Apron. Resident #161 was interviewed on 7/11/17 at 1:15 PM and stated that a few weeks ago a cigarette fell out of his hand and burned a hole in his shirt, and that is why he wears a Smoking Apron, but he does not know why there are some days when he is not given an apron to wear. A facility policy dated 6/07 titled Smoking Policy documented that residents who are determined to be unsafe smokers must wear Smoking Aprons. 415.11(c)(3)(ii)

Plan of Correction: ApprovedJuly 26, 2017

F282
1. The affected resident #161 was provided with a smoking apron starting at the 1:15pm smoking session on 7/10/17.

2. All smoking residents have the potential to be affected by this practice. The smoking device list was reviewed and updated for all residents requiring smoking devices. Director of Recreation/Designee has and will continue to attend smoking sessions on a random basis to monitor compliance with the smoking device list.
3. All recreation staff were re-inserviced with return demonstration by the Recreation Director/Designee on utilization of the Smoking Device List to ensure that all residents requiring a smoking device are utilizing same appropriately. A New Smoking Communication Log was implemented to allow the recreation staff to communicate with the Recreation Director/Designee any noted changes during smoking sessions. A new ?Smoking Device Audit Tool? was implemented. See below.
4. The Recreation Director/Designee will maintain the Smoking Device Audit Tool and the Smoking Log and visit smoking sections on a random basis twice a week x3 months and then weekly thereafter. Audit of the smoking device compliance will be maintained and reported to the QA meetings at scheduled meetings or quarterly.

5. Director of Therapeutic Recreation/Designee

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

REGULATION: Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 12, 2017
Corrected date: September 8, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 99: 10.5.2.1 Testing Intervals. 2012 NFPA 99: 10.5.2.1.1 The facility shall establish policies and protocols for the type of test and intervals of testing for patient care-related electrical equipment. 2012 NFPA 99: 10.5.2.1.2 All patient care-related electrical equipment used in patient care rooms shall be tested in accordance with 10.3.5.4 or 10.3.6 before being put into service for the first time and after any repair or modification that might have compromised electrical safety. Based on observation, staff interview and documentation review, the facility did not ensure that policies and procedures were established for testing patient care-related electrical equipment (PCREE) in accordance with NFPA 99. This was noted on one of two resident sleeping floors. The findings are: On 7/10/17 between 8:45am- 2:00pm during the recertification survey, patient care-related electrical equipment, such as an oxygen concentrator and a nebulizer, was observed in resident room [ROOM NUMBER] lacking inspection stickers. In an interview on 7/10/17 at approximately 9:00am, the Director of Environmental Services stated that oxygen concentrators and nebulizers are inspected by an outside company. He further stated that he would contact the company and provide the inspection report by the survey exit date. There was no documentation provided at the time of survey regarding policies and protocols for the type of test and intervals of testing for oxygen concentrators and nebulizers. 2012 NFPA 99: 10.5.2.1, 10.5.2.1.1, 10.5.2.1.2 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedAugust 17, 2017

Element #1
The facility Maintenance Director has received the inspection report for the concentrators in the facility from the outside company which supplies them.
Element #2
All residents utilizing oxygen concentrators and nebulizers were potentially affected by this deficiency. Facility will compose and implement a code compliant policy for oxygen concentratrators and nebulizers.
Element #3
Policy will state that all new concentrators arriving will be tested and proof of testing be upon arrival or on the next business day after arrival. If a concentrator is found to not have adequate proof of inspection, an inspection will immediately be ordered or performed, and/or a new machine will be ordered.

Element#4
All equipment will be inspected and/or checked for proof of inspection monthly X 3 and quarterly thereafter and results submitted to QAPI.
Element #5
The facility Maintenance Director/Designee will be responsible for ensuring the plan of correction is implemented.

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 12, 2017
Corrected date: September 8, 2017

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not ensure that portable oxygen cylinders were separated five feet from combustibles in the main exterior storage location. The findings include: During the Life Safety Code survey conducted on 7/10/17 at approximately 10:00am, it was noted that combustible plastic crates were kept within 5 feet of portable oxygen cylinders in the main exterior storage location. For example, two plastic crates were noted resting on top of the oxygen cylinders, and oxygen cylinders were noted stored in two plastic crates. In an interview at this time, the Director of Maintenance stated that the oxygen delivery company may have delivered the oxygen cylinders in the plastic crates. He further stated that this issue would be addressed. 2012 NFPA 99: 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 2012NFPA101 NYCRR 711.2(a) 10 NYCRR 415.29

Plan of Correction: ApprovedAugust 17, 2017

Element #1
The facility Maintenance Director ordered and received 2 additional metal oxygen storage racks for the oxygen outdoor storage room and in-serviced the oxygen company about delivering the oxygen in plastic crates.
Element #2
All residents were potentially affected by this deficiency. All plastic crates have been removed from the vicinity of oxygen cylinders.
Element #3
The facility Maintenance Director or Designee will inspect the oxygen storage room after every delivery to ensure that the company is not delivering oxygen cylinders in plastic crates.

Element#4
The facility Maintenance Director will incorporate these inspections into the existing monthly building inspection and will report the findings to the Quality Assurance Committee on a quarterly basis.
Element #5
The facility Maintenance Director/Designee will be responsible for ensuring the plan of correction is implemented.

K307 NFPA 101:HVAC

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

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: July 12, 2017
Corrected date: September 8, 2017

Citation Details

K-521 S/S=B The following requirements of The Life Safety Code have been previously waived. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the conditions under which the waivers have been granted have not changed. Please indicate if the facility wishes that waiver(s) to be continued. K-521 Vertical Ventilation ducts that passed through floors were not protected in accordance with the requirements of NFPA 90A, Standard for the Installation of Air-conditioning and Ventilating Systems. NFPA [PHONE NUMBER]: 19.5.2.1, 9.2, NFPA 90A-2012, NYCRR 711.2(a) 10 NYCRR 415.29

Plan of Correction: ApprovedAugust 17, 2017

Facility requests continuation of the waiver.

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: Widespread
Severity: Potential to cause minimal harm
Citation date: July 12, 2017
Corrected date: September 8, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview during the recertification survey, it could not be determined that sprinkler assemblies were installed as per manufacturer's recommendation. Reference is made to sprinkler Escutcheons for pendant sprinklers that were installed in the downright orientation on 3 of 3 floors inspected for compliance. The findings are: During the Life Safety Code survey conducted on 7/10/17 between 8:30am and 1:00pm, it was noted that the Escutcheon rings, that were part of the pendent sprinkler assemblies, were installed in the downright orientation around the sprinkler heads instead of flush with the ceiling. Examples included but are not limited to the following locations: - 2nd floor: within the West Emergency Exit Stairwell, in the Nursing Office, in resident rooms 206, and 204. - 1st floor: within the Clinical Staff room, in the Dining room, in the resident common shower room, and resident room [ROOM NUMBER]. - Lower level: within the beauty parlor. In an interview on the same day at approximately 9:45am, the Director of Maintenance stated that the sprinklers were recently replaced and that he would contact the Administrator to provide the manufacturer's installation recommendations for the Escutcheons rings. The facility did not provide the requested documentation for the sprinkler Escutcheon ring installation by the conclusion of the survey. 2012 NFPA 101: 19.3.5.1, 9.7. 2010 NFPA 13 10NYCRR 711.2(a)(1) 10 NYCRR 415.29

Plan of Correction: ApprovedAugust 17, 2017

1. All noted escutcheons will be replaced by code compliant escutcheons installed in accordance with manufacturer instructions.
2. All other sprinkler escutcheons will be checked by vendor or DES/Designee and replaced as necessary.
3. In the event of any changes in or additions to sprinklers, DES/Designee will monitor work product to assure that proper escutcheons are installed according to manufacturer instructions.
4. Sprinkler head compliance will be added to quarterly maintenance QA and results reported to QAPI committee.
5. DES/Designee

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: July 12, 2017
Corrected date: September 8, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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: 5.3.1.1.1.6* Dry sprinklers that have been in service for [AGE] years shall be replaced or representative samples shall be tested and then retested at 10-year intervals. 2011 NFPA 25: 5.4.1.4* A supply of spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced. 2011 NFPA 25: 5.4.1.4.1 The sprinklers shall correspond to the types and temperature ratings of the sprinklers in the property. This requirement is not met as evidenced by: Based on observation and staff interview during the recertification survey, the facility did not ensure that a spare supply of the dry type pendent sprinkler heads were maintained on the premises. The findings are: During the Life Safety Code survey conducted on 7/10/17 at approximately 9:55am, a review of the facility's supply of spare sprinklers revealed that there was no spare supply of the dry type sprinklers that were observed in the walk-in refrigerator and freezer on the lower level main kitchen. In an interview at this time, the Director of Maintenance stated that he would contact the sprinkler maintenance company to deliver a spare supply of the dry type sprinklers. 2012 NFPA 101: 9.7.5 2011 NFPA 25: 5.3.1.1.1.6, 5.4.1.4, 5.4.1.4.1 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedAugust 17, 2017

1. Spare sprinkler has been ordered.
2. All residents have potential to be affected. Spare sprinklers are anticipated to be in facility not later than P(NAME) date of completion.
3. Spare sprinkler heads will be held in storage in accordance with code.
4. Inventory of spare sprinkler heads will be added to Maintenance QA and done quarterly. Any variance in inventory will be reported to QA.
5. DES/Designee