Our Lady of Peace Nursing Care Residence
June 7, 2016 Certification/complaint Survey

Standard Health Citations

FF09 483.25(d):NO CATHETER, PREVENT UTI, RESTORE BLADDER

REGULATION: Based on the resident's comprehensive assessment, the facility must ensure that a resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; and a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 7, 2016
Corrected date: August 1, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 6/7/16, the facility did not ensure that a resident with an indwelling catheter (a tube inserted into the bladder to drain urine) received the appropriate care and services to prevent urinary tract infection. One (Resident #284) of one resident observed for indwelling catheters had catheter drainage bag and catheter tubing positioned directly on the floor. The finding is: 1. Resident #284 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 4/28/16 revealed the resident is cognitively intact, is understood, and understands. Further review of the MDS revealed the resident has an indwelling catheter. Observation of AM Care (morning hygiene routine) on 6/6/16 at approximately 8:11 AM revealed certified nurse aide (CNA) #1 ambulated the resident from the bed to the toilet, where the resident sat on the toilet. The front (clear side) of the urinary drainage bag and approximately twelve inches of the tubing were lying directly on the floor of the bathroom. CNA #1 assisted the resident with washing his face, arms, hands, and back. At approximately 8:24 AM CNA #1 donned the resident's underpants and sweatpants, passing the urinary drainage bag and tubing through the right pant leg. CNA #1 then placed the urinary drainage bag back (solid) side directly on the bathroom floor with approximately twelve inches of tubing lying directly on the bathroom floor. At approximately 8:27 AM CNA #1 attached the urinary drainage bag to the rolling walker (RW) that was located in front of the resident, removing the drainage bag and tubing from lying directly on the floor. During an interview with CNA #1 on 6/6/16 at approximately 8:45 AM the CNA stated, We don't want the bag to touch the ground because that will contaminate the bag.Usually I empty the bag and put it on the walker, today the bag was empty and I think that threw me off. Review of Physician's Verbal Order dated 5/26/16 revealed the following: -[MEDICATION NAME](antibiotic medication) 500 mg (milligrams). Give 1 tablet by mouth two times a day for UTI for 10 days. Review of the Medication Administration Record [REDACTED]. Interview with the Registered Nurse (RN) Unit Manager on 6/6/16 at approximately 11:56 AM revealed, The drainage bag should be hung from the walker when a resident is sitting on the toilet, never want the bag or tubing to touch the floor.Touching the floor would present a high risk for infection. Further interview revealed the resident recently (5/26/16) underwent a cystoscopy (a diagnostic test to inspect the interior lining of the bladder and urethra) when the urologist diagnosed a UTI. 415.12(d)(1)

Plan of Correction: ApprovedJune 24, 2016

F315
Corrective Action for Affected Resident:
? Resident #284's catheter drainage bag and catheter tubing was properly placed on the walker. Resident #284 was re-assessed for any signs or symptoms of a urinary tract infection by the attending MD and has none.
? Re-education with the C.N.A. involved with Resident #284 on proper placement of the catheter drainage bag and catheter tubing was provided by the Education Coordinator.
Identification of Affected Residents and Corrective Action:
?All residents who have a catheter bag and tubing are identified as having the potential to be affected.
?The Unit Managers/Nursing Supervisors will conduct an Catheter Care Audit of all residents with catheter bags/tubing to assure proper placement of catheter bag/tubing during care episodes.
?Any staff requiring re-education will be provided with re-education.
Measures or Systematic Changes to Prevent Recurrence:
?The Policy and Procedure on Catheter Care was revised to include proper placement during care episodes.
?Re-education including the Catheter Care Policy will be provided to all CNAs by the Education Coordinator or designee.
?A Catheter Care Audit will be conducted on four residents each month by Nursing Administration. Immediate correction of any areas requiring it will be made in addition to re-education and/or disciplinary measures.
How corrective action is monitored and Person Responsible:
?The Catheter Care Audit completed by the Unit Managers/Nursing Supervisors will be forwarded to the Director of Nursing for review and analysis of trends on a weekly basis.
?The Director of Nursing will compile statistical data on a monthly basis. Trend analysis data will be presented monthly to the QI Committee by the Director of Nursing for evaluation and recommendations for improvements as needed.

The responsibility of attaining and maintaining compliance of F315 is assigned to the Director of Nursing.

FF09 483.75(l)(1):RES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE

REGULATION: The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized. The clinical record must contain sufficient information to identify the resident; a record of the resident's assessments; the plan of care and services provided; the results of any preadmission screening conducted by the State; and progress notes.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 7, 2016
Corrected date: August 1, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a Standard survey completed on 6/7/16, it was determined that the facility did not maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete and accurately documented. One (Resident #11) of 14 residents' clinical records were not accurately documented. Nurses Notes did not accurately reflect a resident's health care proxy was notified in regards to various medication changes specifically [MEDICATION NAME] (a blood thinner) to Eliquis (medication to help prevents platelets in your blood sticking together and forming a clot) in 11/2015 and an increase in [MEDICATION NAME] (antianxiety) and discontinuation of [MEDICATION NAME] (antidepressant) in 4/2016. The findings are: 1. Resident #11 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 4/26/16 revealed the resident has severe cognitive impairment. Review of the Physicians Orders dated 11/13/15 revealed an order to D/C (discontinue) [MEDICATION NAME] and start Eliquis 5 mg (milligrams) po (by mouth) twice a day. Review of the 11/2015 MAR (Medication Administration Review) revealed the resident's [MEDICATION NAME] was discontinued on 11/13/15 and Eliquis 5 mg po twice a day was initiated. Review of the Nursing Progress Notes dated 11/1/15 through 11/30/15 revealed no documentation that the health care proxy was notified of the change of medication from [MEDICATION NAME] to Eliquis. Review of the Psychological Services Consultation dated 3/31/16 revealed the following comments and recommendations: Patient with anxiety signs and symptoms, mild depression, moderate impaired cognitive function: patient with increased frustration: recommend discontinuing the [MEDICATION NAME] and changing the [MEDICATION NAME] to two times per day: monitor mood and depression signs and symptoms: if depression increases consider a different anti-depressant: music may benefit his mood: follow up one to two times per month as needed. Review of the Physicians Orders dated 4/4/16 revealed a verbal order to discontinue [MEDICATION NAME] 0.5 mg po qd (daily) and [MEDICATION NAME] 10 mg po qd. Start [MEDICATION NAME] 0.5 mg po twice daily for anxiety and major [MEDICAL CONDITION]. Review of the MAR indicated [REDACTED]. Review of the Nursing Progress Notes dated 3/15/16 through 4/15/16 revealed no documentation that the resident ' s Health Care Proxy was notified of the medication changes during this time frame. During an interview on 6/3/16 at 10:33 AM the resident's spouse stated They never notify me of any changes in medication, treatments. Im not sure if he's had changes in his medications. They do call me when he falls. During an interview on 6/7/16 at 9:31 AM Registered Nurse (RN#2)stated The family is verbally updated on a daily basis.They are here every day because he has quite a few behaviors.The family was involved in the consult with the Psychologist, but I do not see any supporting documentation that the health care proxy was notified in regards to the medication changes.There should be documentation in the Nursing Notes that the family was updated with the changes. Interview with the DON (Director of Nursing) on 6/7/16 at 10:33 AM revealed the resident's family is in the facility on a daily basis, verbally updated on information and is highly involved with the residents care. It is expected of the Nurses to document in the Nurses Notes if there are such changes in medications. 415.22(a)(1-2)

Plan of Correction: ApprovedJune 24, 2016

F514
Corrective Action for Affected Resident:
? Resident #11's health care proxy was contacted and a review of all medications and the plan of care was conducted by the Unit Manager and documented in the EMR on (MONTH) 8, (YEAR).
? Re-education of the nurses involved with Resident #11's medication changes was provided by the Unit Manager to include updating the Health Care Proxy and documenting it in the EMR.
Identification of Affected Residents and Corrective Action:
?All residents who have a medication change are identified as having the potential to be affected.
?The Unit Managers/Nursing Supervisors will conduct a Medication Change/Responsible Party Update Audit of all residents with medication changes in the past 30 days to assure proper notification and documentation of update is in the EMR.
?Any lacking Responsible Party updates will be provided and any staff requiring re-education will be provided by the Unit Manager/Supervisor.
Measures or Systematic Changes to Prevent Recurrence:
?The Policy and Procedure on Medication Orders/Administration was revised to specifically include updating the Resident's Responsible Party and documenting the same in the EMR.
?Re-education including the Medication Orders/Administration Policy will be provided to all LPNs and RNs by the Education Coordinator or designee.
?A Medication Change/Responsible Party Update Audit will be conducted on at least 6 residents each week by Unit Managers/Nursing Supervisors. Immediate correction of any areas requiring it will be made in addition to re-education and/or disciplinary measures.
How corrective action is monitored and Person Responsible:
?Medication Change/Responsible Party Update Audit completed by the Unit Managers/Nursing Supervisors will be forwarded to the Director of Nursing for review and analysis of trends on a weekly basis.
?The Director of Nursing will compile statistical data on a monthly basis. Trend analysis data will be presented monthly to the QI Committee by the Director of Nursing for evaluation and recommendations for improvements as needed.

The responsibility of attaining and maintaining compliance of F514 is assigned to the Director of Nursing.

FF09 483.15(e)(2):RIGHT TO NOTICE BEFORE ROOM/ROOMMATE CHANGE

REGULATION: A resident has the right to receive notice before the resident's room or roommate in the facility is changed.

Scope: Isolated
Severity: Potential to cause minimal harm
Citation date: June 7, 2016
Corrected date: N/A

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident #407 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool), dated 5/3/16 revealed the resident is cognitively intact, understands and is understood. During an interview with Resident #407 on 6/3/16 at 9:33 AM, the resident stated she has had three roommates since admission to the facility. The resident stated she was not informed prior to receiving new roommates. Review of Resident #407's face sheet revealed the resident was admitted to the facility on [DATE]. Review of the Detailed Census Report for (MONTH) through (MONTH) (YEAR) revealed that Resident #407 was assigned to a semi private room on 4/26/16. Further review of the Detailed Census Report revealed that Resident #407 received a new roommate on 4/30/16 and a second roommate on 5/27/16. Review of the Progress Notes, dated 4/26/16 through 4/30/16 and 5/22/16 through 5/28/16, revealed no documented evidence that Resident #407 was notified when new roommates were assigned to the room. During an interview with the Social Worker (SW #1) on 6/7/16 at 8:30 AM, SW #1 stated that she will verbally inform residents on the subacute unit (Resident #407's assigned unit) of the admission of a new roommate but has not documented that notification. SW #1 stated she could not definitely remember if Resident #407 was notified of the assignment of new roommate on 4/30/16 and stated she was not working on 5/27/16, and other staff members would have been responsible to inform Resident #407 of the assignment of a new roommate on that date. SW #1 continued to state she did not document notification of new roommates for any resident on the subacute unit. During an interview with the Registered Nurse Director of Nursing (DON) on 6/7/16 on 10:42 AM, the DON stated that when the SW and nursing staff review admission paperwork with a new patient on the subacute unit, staff discuss the concept of a short term stay on the unit and the possibility of roommate changes. The DON stated that the facility had not documented notification of each roommate change for patient on the subacute unit but will now begin to document that notification. 415.5(e)(2)

Plan of Correction: ApprovedJune 20, 2016

A plan of correction is not required for deficiencies at scope and severity level A. The facility remains responsible to expeditiously correct all deficiencies and to ensure measures are in place to maintain compliance. Please submit this information to the Department to acknowledge this message.

FF09 483.20(d)(3), 483.10(k)(2):RIGHT TO PARTICIPATE PLANNING CARE-REVISE CP

REGULATION: The resident has the right, unless adjudged incompetent or otherwise found to be incapacitated under the laws of the State, to participate in planning care and treatment or changes in care and treatment. A comprehensive care plan must be developed within 7 days after the completion of the comprehensive assessment; prepared by an interdisciplinary team, that includes the attending physician, a registered nurse with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident's needs, and, to the extent practicable, the participation of the resident, the resident's family or the resident's legal representative; and periodically reviewed and revised by a team of qualified persons after each assessment.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 7, 2016
Corrected date: August 1, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED ON 4/13/15. Based on interview and record review conducted during the Standard Survey completed on 6/7/16, the facility did not periodically review and revise the Comprehensive Care Plan. Two (Residents #159, 264) of 14 residents reviewed for Care Plans had did not have Care Plan revisions to include changes with diuretic, diabetic (Resident #159) and anticoagulant (Residents #159, 264) medications. The findings are: 1. Resident #159 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 5/5/16 revealed the resident is cognitively intact, is understood and understands. Review of the Medication Review Report, on or after date 3/11/16, included the following: - [MEDICATION NAME] ([MEDICATION NAME]. Diuretic medication that promotes the excretion of urine) Give 20 milligram (mg) by mouth two times a day for [MEDICAL CONDITION] (swelling caused by excess fluid accumulation) - Eliquis (anticoagulant medication used to prevent blood from clotting) give 2.5 mg orally two times a day related to acute venous (relating to vein) embolism and [MEDICAL CONDITION] (clotting within a blood vessel). Review of Phone Order dated 3/20/16 revealed the following order: - Humalog Solution (Insulin) 100 unit/ml (milliliter) inject as per sliding scale subcutaneously before meals and at bedtime: If 0 - 120 = 0 units 121 - 200 = 5 units 201 - 250 = 8 units 251 - 300 = 12 units 301 - 350 = 16 units 351 - 400 = 20 units If over 400, give 20 units and recheck in 1 hr (hour); If recheck is less than 400, do not give any more insulin, monitor BS (blood sugar) at next scheduled time. Review of the Comprehensive Care Plan, Last Care Plan Review Dated 6/3/16, included the following: - Focus: The resident is on diuretic therapy ([MEDICATION NAME] 20mg daily) r/t (related to) hypertension. Goal: The resident will be free of any discomfort or side effects of diuretic therapy through next review date. Interventions: Administer diuretic medications as ordered by physician. Monitor for side effects and effectiveness Q (every) shift. - Focus: Potential for blood clot r/t (related to) dx (diagnosis) venous [MEDICAL CONDITION]. Medication - Xarelto (anticoagulant medication used to prevent blood from clotting) daily D/C (discontinue). Goal: Resident will not develop blood clot through next review. Interventions: Monitor for s/sx (signs/symptoms) of blood clot, such as pain, swelling, Discoloration, SOB (shortness of breath), headache. - Focus: Potential for altered glucose levels r/t dx Diabetes Mellitus. Medication [MEDICATION NAME] (oral blood glucose lowering drug) FSBS (finger stick blood sugar) at 0630 (6:30am) and 1630 (4:30pm) with no coverage, notify MD <80 or >400. Goal: Resident ' s blood sugar will be within acceptable limits as determined by the MD/NP (nurse practitioner). Interventions: Diet as ordered. Finger stick blood sugars as ordered and prn (as needed). Medications and labs per order. Interview with the Registered Nurse (RN) Unit Manager on 6/6/16 at approximately 11:43 AM revealed, the resident is on Eliquis not Xarelto, both are anticoagulants but are different medications. In addition the interview with the RN Unit Manager revealed, the resident receives [MEDICATION NAME] twice a day and the resident is receiving sliding scale insulin coverage (dose of insulin based on blood glucose level). RN Unit Manager stated, And this is why my DON (Director of Nursing) said not to put specifics on the Comprehensive Care Plan. The Care Plan should have been updated whenever any changes are made. 2. Resident #264 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has severe cognitive impairment, is understood and understands. Review of the Comprehensive Care Plan, Revision 6/6/16, included the following: - Focus: Nutrition - Dx (diagnosis): Acute [MEDICAL CONDITIONS] [MEDICAL TREATMENT] tx (treatment), [MEDICATION NAME] (anticoagulant medication used to prevent blood from clotting). Review of the Medication Review Report, signed by the Physician on 4/26/16, revealed no current physician's orders [REDACTED]. Interview with the Registered Nurse (RN) Unit Manager on 6/6/16 at approximately 11:43 AM revealed, the resident is no longer receiving [MEDICATION NAME]. The [MEDICATION NAME] was D/C ' d in (MONTH) of (YEAR). Interview further revealed the Comprehensive Care Plan was reviewed 2/5/16 and 3/31/16 and the [MEDICATION NAME] probably should not be on the Care Plan. 415.11(c)(2)(iii)

Plan of Correction: ApprovedJune 24, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F280
Corrective Action for the Affected Residents:
? A Plan of Care review for Residents #159 and #264 was conducted by Nursing Administration on 6/8/16. The review revealed that on 6/6/16 the Unit Manager immediately revised the plan of care regarding the diuretic therapy and the current utilization of insulin based on a sliding scale when brought to her attention. On 6/8/16 Resident #159's plan of care was also revised to reflect the current anticoagulant medication utilized. Resident #264's nutritional plan of care was corrected and the use of [MEDICATION NAME] therapy was removed to reflect current MD orders.
? Immediate re-education was provided to the Unit Manager regarding care plan updates and revisions by the Director of Nursing.
Identification of Affected Residents and Corrective Action:
? All residents have the potential to be affected by untimely medication care plan updates. The facility will identify those residents through the completion of an MDS/Care Plan Review Audit by the Unit Managers.
? The Unit Manager will be responsible for ensuring necessary updates and/or revisions to the plan of care are completed timely. Corrective action will include time/date stamp via electronic signature in the EMR by the Unit Manager/Supervisor upon receipt of MD medication orders that impact the plan of care.
Measures or Systematic Changes to Prevent Recurrence:
? Review/Revision to Policy for Plan of Care Development and Implementation will include additional guidance and timeframes for required updates.
? All Unit Managers/Supervisors will be in-serviced on the revised Policy: Plan of Care Development and Implementation by Nursing Administration.
? All Unit Managers will complete a MDS/Care Plan Review Audit with each resident's scheduled Annual/Quarterly/Significant Change assessments.
How Corrective Action is Monitored and Person Responsible:
? The MDS/Care Plan Review Audits will be turned into Nursing Administration on a weekly basis.
? The Assistant Director of Nursing or designee will compile statistical data on a monthly basis. Trend analysis data will be presented monthly to the Quality Assurance Committee by the Assistant Director of Nursing, or designee, for evaluation and recommendations for improvements as needed.
The responsibility of attaining and maintaining compliance is assigned to the Director of Nursing.

Standard Life Safety Code Citations

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Smoke barriers shall be constructed to provide at least a one half hour fire resistance rating and constructed in accordance with 8.3. Smoke barriers shall be permitted to terminate at an atrium wall. Windows shall be protected by fire-rated glazing or by wired glass panels and steel frames. 8.3, 19.3.7.3, 19.3.7.5

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 7, 2016
Corrected date: August 1, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEYS COMPLETED ON 3/31/14 AND 4/13/15. Based on observation and interview during a Life Safety Code survey completed on 6/7/16, smoke barrier walls were not completed from floor to ceiling, were not designed to have at least a 30 minute fire resistance rating, and were not designed to resist the passage of smoke. This affected three (First, Second, Third Floors) of three resident use floors. The findings are: 1. Observation above the ceiling tiles on the Third Floor on 6/3/16 at approximately 9:28 AM revealed four approximate 12 inch long by two inch wide penetrations in the smoke barrier wall above the smoke barrier door near the Three East unit nurse's station were filled with mineral wool that was not sealed with a fire rated material. Further observation at this time revealed the penetrations were located on the nurse's station side of the smoke barrier doors between the gypsum board smoke barrier wall and the corrugated ceiling. Interview with the Facilities Director at the time of the observation revealed the penetrations that were filled with mineral wool that were not sealed with a fire rated material were from the building's original construction. 2. Observation above the ceiling tiles on the Third Floor on 6/3/16 at approximately 10:37 AM revealed an approximate one inch long by one quarter inch wide open unsealed penetration between two pieces of the gypsum board smoke barrier wall near the Three West unit nurse ' s station. Further observation at this time revealed the open, unsealed penetration was on the center core corridor side of the smoke barrier wall to the left of the smoke barrier doors located near the nurse's station. 3. Observation above the ceiling tiles on the Third Floor on 6/3/16 at approximately 10:47 AM revealed an approximate 12 inch long by one quarter inch wide open, unsealed penetration between two pieces of the gypsum board smoke barrier wall that ran through the Three West unit nurse's station. 4. Observation on the Third Floor on 6/3/16 at approximately 10:50 AM revealed two approximate one inch long by one half inch wide open, unsealed penetrations in the smoke barrier wall that ran through the Three West unit medication storage room. Further observation at this time revealed the penetrations were located around two pipes that were installed through the smoke barrier wall under the sink located in the room. 5. Observation above the ceiling tiles on the Third Floor on 6/3/16 at approximately 11:00 AM revealed an approximate two inch long by one half inch wide open, unsealed penetration around two yellow electrical lines that were installed through the smoke barrier wall above the Three West unit smoke barrier doors located near Resident room [ROOM NUMBER]. Interview with the Facilities Director at the time of the observation revealed he was not aware of any wiring being recently installed through the smoke barrier wall. 6. Observation above the ceiling tiles on the Second Floor on 6/3/16 at approximately 11:40 AM revealed an approximate three inch long by two inch wide penetration in the smoke barrier wall above the Two East unit smoke barrier doors located near Resident room [ROOM NUMBER] was filled with mineral wool that was not sealed with a fire rated material. 7. Observation above the ceiling tiles on the Second Floor on 6/3/16 at approximately 11:50 AM revealed an approximate three inch long by one inch wide penetration in the smoke barrier wall above the Two East unit smoke barrier doors located between Resident room [ROOM NUMBER] and the dining room was filled with mineral wool that was not sealed with a fire rated material. 8. Observation above the ceiling tiles on the First Floor on 6/3/16 at approximately 1:46 PM revealed an approximate five inch long by one inch wide penetration in the smoke barrier wall above the smoke barrier doors near the One West unit nurse's station was filled with mineral wool that was not sealed with a fire rated material. Further observation at this time revealed the penetration was located on the center core side of the smoke barrier doors located near the nurse's station. 9. Observation on the First Floor on 6/3/16 at approximately 1:58 PM revealed an approximate one inch long by one half inch wide open unsealed penetration in the smoke barrier wall that ran through the One West unit nurse's station. Further observation at this time revealed the penetration was located next to a calendar that was hung on the wall. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2000 NFPA 101: 19.3.7, 19.3.7.3, 8.3, 8.3.1, 8.3.2

Plan of Correction: ApprovedJune 27, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K025:
Immediate Corrective Action Taken:
1) The four approximate 12 inch long by two inch wide penetrations in the smoke barrier wall above the smoke barrier door located on the nurse's station side of the smoke barrier doors between the gypsum board smoke barrier wall and the corrugated ceiling near the 3E unit nurse's station were sealed with fire rated material.
2) The approximate one inch long by one quarter inch wide open, unsealed penetration on the center core corridor side of the smoke barrier wall to the left of the smoke barrier doors between two pieces of the gypsum board smoke barrier wall near the 3W unit nurse's station was sealed with fire rated material.
3) The approximate 12 inch long by one quarter inch wide open, unsealed penetration between two pieces of the gypsum board smoke barrier wall that ran through the 3W unit nurse's station was sealed with fire rated material.
4) The two approximate one inch long by one half inch wide open, unsealed penetrations in the smoke barrier wall located around two pipes that were installed through the smoke barrier wall under the sink located in the 3W unit medication storage room was sealed with fire rated material.
5) The approximate two inch long by one half inch wide open, unsealed penetration around two yellow electrical lines installed through the smoke barrier wall above the 3W unit smoke barrier doors located near Resident room [ROOM NUMBER] were sealed with fire rated material.
6) The approximate three inch long by two inch wide penetration in the smoke barrier wall above the 2E unit smoke barrier doors located near Resident room [ROOM NUMBER] was sealed with fire rated material.
7) The approximate three inch long by one inch wide penetration in the smoke barrier wall above the 2E unit smoke barrier doors located between Resident room [ROOM NUMBER] and the dining room was sealed with fire rated material.
8) The approximate five inch long by one inch wide penetration in the smoke barrier wall on the center core side of the smoke barrier doors located near the nurse's station above the smoke barrier doors near the 1W unit nurse's station was sealed with fire rated material.
9) The approximate one inch long by one half inch wide open unsealed penetration in the smoke barrier wall that ran through the 1W unit nurse's station near the calendar that was on the wall was sealed with fire rated material.
A Root Cause Analysis was conducted on the breaches to the smoke barrier walls.
A letter outlining our corrective action by convening the Quality Assurance Committee was submitted to the Program Director of the WRO.
Identification of Other Potentially Affected Areas:
An inspection of all smoke barrier walls was conducted throughout the facility by the Maintenance Staff.
Any additional areas identified areas were sealed with fire rated material.
Measure/Systems To Prevent Recurrence:
- All maintenance staff will be re-educated on the importance of Life Safety Code K025 by the Director of Facilities.
- Outside contractors will be educated and held accountable for compliance/reporting of penetrations.
- The Quality Assurance Committee convened on (MONTH) 22, (YEAR) to conduct an assessment of the causative factors, identify interventions to correct causative factors, identify inspection parameters and determine how the facility will measure successful compliance.
Monitoring of Corrective Action:
The Director of Facilities, or designee, will conduct a Smoke Barrier Wall Audit monthly or as needed and after any contruction work is completed. Smoke Barrier Wall Audit identifying any penetrations will be repaired with fire rated material.
Violations will be addressed through discipline and/or re-education. The Director of Facilities will analyze these audits for trends and intervention.
Trend analysis data will be presented monthly to the Quality Assurance Meetings by the Director of Facilities for evaluation and recommendation for improvement as needed.
The person responsible for compliance of K025 is the Director of Facilities.

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Cooking facilities are protected in accordance with 9.2.3. 19.3.2.6, NFPA 96

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 7, 2016
Corrected date: July 12, 2016

Citation Details

Based on interview and record review conducted during a Life Safety Code survey completed on 6/7/16, the kitchen hood extinguishment system was not inspected at least every six months. This affected one of one main kitchen. The findings are: 1. Record review of range hood suppression system reports on 6/3/16 revealed the main kitchen ' s hood extinguishment system was inspected on 5/6/15 and 1/13/16. A period of approximately eight months. Interview with the Facilities Director on 6/7/16 at approximately 8:22 AM revealed the kitchen hood extinguishment system was inspected on 5/6/15 and 1/13/16 and no other inspections and been conducted between these two dates. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2000 NFPA 101: 19.3.2.6

Plan of Correction: ApprovedJune 24, 2016

K069:
The immediate corrective action taken:
The range hood suppression system will be inspected before (MONTH) 13, (YEAR) to ensure compliance with inspection every six months.
The following corrective actions will be implemented to identify other residents that may be affected by the same practice:
All residents are identified to have the potential to be affected by the same practice.
A monthly inspection checklist will be reviewed by the Director of Facilities to assure inspections are completed at proper intervals.
The following system changes will be implemented to assure continuing compliance with regulations:
- The vendor contracted to complete the range hood suppression inspection will be re-educated on the requirements of Life Safety Code K069 related to the kitchen's hood extinguishment system by the Director of Facilities.
- A monthly inspection checklist of the building will be conducted by the Director of Facilities, or designee, to assure compliance with Life Safety Code K069.
The corrective action will be monitored by:
- Inspection Reports will be reviewed by the Director of Facilities on a monthly basis for compilation and analysis. Corrective action will be initiated for any items requiring it.
Trend analysis data will be presented monthly to the QA/IOP Team by the Director of Facilities for evaluation and recommendations for improvement as needed.
The person responsible for assuring correction of K069 is the Director of Facilities