Masonic Care Community of New York
January 4, 2018 Certification/complaint Survey

Standard Health Citations

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

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

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

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the recertification survey, the facility did not ensure adequate supervision was provided to prevent accidents for 1 of 12 residents (Resident #125) reviewed. Specifically, Resident #125 was observed with oral medications on a napkin on her tray in her room and there was no order for the resident to self-medicate. Findings include: The facility's policy and procedure for medication administration revised 11/2017 documented the following: -The nurse will remain with the resident until the medication is swallowed. -Do not leave medication with the resident to be taken at a later time unless ordered by medical and care planned. 1) Resident #125 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 1/5/2018 at 11:20 AM the resident was observed in bed with her tray table in front of her. Thirteen pills were noted on a napkin on the tray and the resident was self-administering the medications. The 1/5/2018 Medication Administration Record [REDACTED] -[MEDICATION NAME] (medication for [MEDICAL CONDITION]) -Levetiracetam (medication for [MEDICAL CONDITION]) -Potassium Chloride (medication for low potassium) -[MEDICATION NAME] (beneficial bacteria to promote digestive health) -[MEDICATION NAME] (vitamin for eye health) -[MEDICATION NAME] (diuretic) -[MEDICATION NAME] (blood thinner) -Carvedilol (medication for heart failure) -Vitamin D3 (vitamin to support bone health) -Tab-A-Vit (vitamin to support nutrition) -Folic Acid (vitamin used to treat [MEDICAL CONDITION]) -[MEDICATION NAME] (medication for [MEDICAL CONDITION]) No other medications were scheduled to be administered until 1:00 PM that day. On 1/5/2018 at 11:35 AM licensed practical nurse (LPN) #18 stated the resident usually ate in the dining room so she could watch her take her medications. The resident wanted to stay in bed that day so the nurse left the medications on the resident's tray and kept checking on the resident in her room; and the resident kept falling asleep. She also stated there was no physician order for [REDACTED]. On 1/5/2018 at 12:00 PM registered nurse (RN), nurse manager (NM) #19 stated she expected her staff who administered medications to stay with the resident until the medications were taken and there should be a physician order if residents were allowed to self-administer their medications. 10NYCRR415.12(h)(2)

Plan of Correction: ApprovedJanuary 23, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective action(s) will be accomplished for the resident found to have been affected by deficient practice?
Immediately upon notification oral medications for Resident #125 were removed from resident?s room and properly administered by nurse.
How will we identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All residents receiving oral medications who do not have a physician order [REDACTED].
Licensed Practical Nurse (LPN) #18 received immediate re-education on medication administration procedures and had a medication pass competency performed.
Full house audit will be conducted by the nurse managers with input from the interdisciplinary team to identify residents who have the ability to self-medicate and to ensure physician order [REDACTED].
What measures will be put in place or what systemic changes will you make to ensure that the deficient practice will not recur?
Medication Administration Policy and Procedure reviewed for any necessary revisions.
Licensed nursing personnel will be re-educated on the following:
? The medication nurse is to stay with the resident until oral medications are swallowed
? The medication nurse is not to leave medication with the resident to be taken at a later time unless the resident has a physician order [REDACTED].
All new licensed nursing personnel will receive education on the above during their initial orientation period and annually thereafter.
Facility will ensure that all licensed nursing personnel are in compliance with the above policy by monitoring during their annual medication pass competency.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
LPN #18 will have medication administration audits performed by the Education department on a weekly basis for 4 weeks, then every 2 weeks for 4 weeks to ensure 100% compliance with properly following medication pass procedures. If sustained compliance is not achieved auditing will continue.
Audit tool will be developed to identify residents who have the ability to self-medicate and to ensure physician order [REDACTED]. This audit will be conducted by the nurse managers with input from the interdisciplinary team monthly for a period of 3 months to achieve 90-100% compliance, then quarterly for a period of one year. If sustained compliance is not achieved, auditing will continue until sustained compliance is achieved. Audit will be reported to the Quality Assessment and Assurance Committee on a quarterly basis throughout the auditing period. In addition, the nurse managers will conduct random audits on a weekly basis x 4 weeks to achieve 100% compliance to ensure that no medications are left in a resident's room unless he/she has an order to self-medicate. If sustained compliance is not achieved, auditing will continue until sustained compliance is achieved. Audit will be reported to the Quality Assessment and Assurance Committee on a quarterly basis throughout the auditing period.
Responsible Person:
Director of Nursing

FF11 483.80(a)(1)(2)(4)(e)(f):INFECTION PREVENTION & CONTROL

REGULATION: §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(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: §483.80(a)(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; §483.80(a)(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. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(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: January 8, 2018
Corrected date: March 8, 2018

Citation Details

Based on observation, record review and interview during the recertification survey, the facility did not ensure that staff maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 11 employees reviewed for influenza (flu) vaccinations. Specifically, four employees did not receive the flu vaccine and were observed not wearing a mask correctly during the designated flu season. Findings include: The facility's Influenza protocol for staff (undated) documented the following: -When the Commissioner of Health declares flu to be prevalent in New York State, staff who has not had a flu shot will be required to wear a mask covering their nose and mouth upon entering the health facility. The New York State Department of Health Commissioner declared Influenza prevalent in the state on 12/13/2017. The following observations were made: -On 1/3/2018 at 8:55 AM resident aide (RA) #22 was wearing his flu mask below his chin while in a resident care area and when the surveyor looked his way, he quickly pulled the mask up covering his mouth and nose. He stated he had not received the flu shot. -On 1/4/2018 at 9:05 AM certified nurse aide (CNA) #21 was wearing her flu mask beneath her nose while in a resident care area and when the surveyor looked her way, she had pulled the mask up covering her nose. She stated she had not received the flu shot. -On 01/04/2018 3:09 PM licensed practical nurse (LPN) #18 who had been observed wearing a flu mask earlier in the day was now without a mask while in a resident care area. She stated she had not received the flu shot. -On 1/4/2018 at 3:14 PM, certified nurse aide (CNA) #20 was standing in the resident living room with a mask pulled down below her chin. There were residents in the living room and she walked to the kitchen and pulled the mask over her mouth. CNA #20 was interviewed and stated she did not get a flu shot and was required to wear a mask. As she talked to the surveyor, she pulled the mask away from her mouth and stated the mask was supposed to be over her mouth and nose, and she was uncovering her mouth to talk. She then stated she did not pull it away from her mouth when she talked to residents. She stated she had the mask down when she was in the living room with the residents and she should have had her mouth and nose covered. The 12/13/2017 class roster for safe donning and removal of personal protective equipment (PPE), including masks, documented CNAs #20 and #21 and RA #22 had completed the training. On 1/4/2018 at 1:45 PM Infection Control nurse #23 stated staff education on the flu had been provided in 11/2017 and 12/2017. The education included wearing a face mask if staff had not received the flu vaccine and proper wearing of a face mask to cover both the nose and mouth. She stated she had spoken to CNA #21 regarding the correct way to wear the flu mask. On 1/4/2018 at 3:09 PM LPN #18 stated she was not wearing her flu mask as it was the end of her shift and she was getting ready to leave. She stated she was going to get her flu shot on her way out and placed a call to the infection control nurse to do so. 10NYCRR 415.19(a)(1-3)

Plan of Correction: ApprovedJanuary 23, 2018

What corrective action(s) will be accomplished for the resident found to have been affected by deficient practice?
The 4 employees identified who had not received a flu shot during the designated flu season were aware of the requirement to wear protective equipment as well as the proper method of applying such protective equipment.
Each of the 4 employees identified were offered the influenza vaccination and were re-educated on when a mask is required to be worn and the proper technique of wearing a mask.
How will we identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All residents are placed at risk by improper mask technique during the designated flu season. Department Directors and Nursing Supervisors informed of the need to monitor to ensure that all employees who did not receive the flu vaccine for the designated flu season were wearing a mask as per policy and procedure. Any necessary corrections were made at the time of the observation.
What measures will be put in place or what systemic changes will you make to ensure that the deficient practice will not recur?
Influenza policy and procedure and mask usage guidance were reviewed for any necessary revisions.
All facility staff will be re-educated on the following. This education will be continue to be provided on an annual basis.
? Regulation requiring all unvaccinated personnel to wear a surgical mask at all times while in areas in which residents may be present during the designated flu season.
? Use of surgical mask including proper donning, positioning, and removal of mask
All new facility staff will be educated on the above items during their initial orientation period and annually thereafter.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
Audit tool will be developed to monitor adherence to the mask requirement during the designated flu season. This audit will be conducted by department directors monthly during the designated flu season for a period of 3 months to achieve 90-100% compliance. If sustained compliance is not achieved, auditing will continue until sustained compliance is achieved. Audit will be reported to the Quality Assessment and Assurance Committee on a quarterly basis throughout the auditing period.
Responsible Person:
Director of Nursing

FF11 483.25:QUALITY OF CARE

REGULATION: § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

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

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification and abbreviated surveys (NY 681), it was determined for 1 of 3 residents reviewed for non-pressure related skin concerns (Resident #556), the facility did not ensure residents received treatment and care in accordance with professional standards of practice. Specifically, - Resident #556 sustained a burn on 11/11/2017 at 3:00 AM when certified nurse aide (CNA) #7 gave the resident a hot towel for pain relief. - After the resident sustained [REDACTED].#7 did not report the burn to a licensed nurse. - The CNA assigned to care for the resident at the time of the incident (CNA #13) documented a skin check was completed and the resident had no new skin concerns after she sustained the burn. - Two registered nurses (RN) administered treatments to the resident's burn without a physician's orders [REDACTED]. Findings include: The facility's policy Warm Moist Compress Application, revised 2/2013, documented the application of warm moist heat required a physician's orders [REDACTED]. Warm compresses could be applied no longer than 20 minutes and rice packs, heating pads, and microwaves were not permitted as the elderly were at increased risk [MEDICAL CONDITION] other complications. Residents were to be observed for any adverse effects and adverse effects were to be reported to the Nurse Manager or Supervisor immediately. Resident #556 was admitted to the facility on [DATE] following a revision of a total right hip. The resident was cognitively intact per the 11/9/2017 Minimum Data Set (MDS) assessment. Review of the medical record from 11/2/2017 through 11/11/2017 revealed the resident did not have an order for [REDACTED]. The 11/11/2017 certified nurse aide (CNA) care documentation specified on 11/11/2017 at 6:39 AM, CNA #13 documented the resident had no new skin issues identified from a skin check. The 11/13/2017 attending physician's progress note documented the resident sustained [REDACTED]. The resident had a warm towel on, fell asleep with it on, and smelled skin burning. The physician documented there was no vesicle (blister) formation and the burn measured around 7 centimeters (cm). The burn had some ecchymosis (discoloration) and yellow discoloration in the outer portion of the area and some [DIAGNOSES REDACTED] (redness) in the middle. A treatment of [REDACTED]. The 11/17/2017 investigative summary signed by Assistant Director of Nursing (ADON) #5 documented: - On 11/11/2017 at 3 AM, the resident requested a warm compress for right inner thigh muscle pain and CNA #7 gave her a heated towel. The resident placed the towel on her thigh and then put her call bell on a short time later because it was too hot. CNA #7 noticed the resident's skin was slightly red and she did not notify a nurse. - On 11/11/2017 at 11:30 PM, the resident asked registered nurse (RN) #14 if she could do something for her leg. RN #14 noted a 4 cm (centimeter) x 7 cm, oval, brownish area on the resident's leg. RN #14 notified RN Supervisor #17 who told her to contact the physician. - On 11/12/2017 in the morning, RN #14 told RN #9 about the resident's burn. RN #9 cleaned and treated the area when the resident complained of pain. RN #14 returned to the facility that night and also applied a treatment to the burn. - On 11/13/2017 at 7:30 AM, the physician was asked to assess the resident and ordered [MEDICATION NAME] treatment. Staff statements with the investigation included: - CNA #7's statements dated 11/12/2017 and 11/15/2017 documented the resident's injury was from a warm towel that she heated up in the dryer and then the microwave and gave to the resident. CNA #7 documented when she took the towel back, she noticed redness on the resident's leg and she did not notify anyone of the incident. - RN Supervisor #17's statement dated 11/17/2017 documented on 11/11/2017, she was on the unit and CNA #7 told her that she warmed up a towel in the microwave to give to a resident. RN #17 documented she told CNA #7 they were not allowed to put anything hot on a resident. - RN #14's statement dated 11/15/2017 documented she worked from 7 PM on 11/11/2017 to 7 AM on 11/12/2017 and at around 8 PM on 11/11/2017, the resident asked her if there was anything she could put on the burn on her leg. RN #14 observed a brownish burn on the resident's thigh and the resident told her it was from a warm towel the night before. RN #14 notified RN Supervisor #17 and applied petroleum jelly to the resident's burn and covered it with Vaseline gauze. She continued to work on the paperwork when she returned to work at 7 PM on 11/12/2017 and on 11/13/2017 at 7:30 AM, when the physician came in she asked him to see the resident. - The resident's assigned CNA when the incident occurred, CNA #13's statement dated 11/12/2017, documented he was not aware of the incident or the burn. - RN #9's statement dated 11/15/2017, documented on 11/12/2017 at 8 AM, she was told in report that the resident had a burn and she was also told about the burn by the resident. She cleansed the area with normal saline and applied Vaseline to relieve the pain. She documented she thought the night nurse who told her about the burn was contacting the physician. On 12/11/2017 at 9:15 AM, CNA #7 stated in an interview, on 11/11/2017 at around 3 AM, the resident asked her for a warm compress for pain. She placed a towel in the dryer and it did not get hot enough so she placed it in the microwave for 1-2 minutes and gave the towel to the resident. The resident said the towel was warm so she was going to place it between the sheet and blanket and she did not stay and see where the resident placed the towel. A few minutes later, the resident rang her call bell and said the towel burned the blanket. She saw the resident's leg was pink and did not tell anyone. She stated she did not document the new skin issue for the resident as she was floating between units that night and the resident's assigned CNA (CNA #13) completed all of the resident's documentation that night. On 12/11/2017 at 1:10 PM RN #9 stated in an interview, she worked on 11/11/2017 at 7 AM and was not aware of the burn that day. On 11/12/2017, when she came on duty, RN #14 told her about the burn and the resident also asked her for a treatment. She applied Vaseline to relieve the resident's pain. She stated she did not ask RN #14 if she called the physician or if a treatment was ordered and did not follow-up to determine if those things were done. On 12/11/2017 at 2 PM, the attending physician stated in an interview, he became aware of the resident's burn on 11/13/2017 when RN #14 told him during his rounds. He stated when he became aware, he assessed the resident and ordered [MEDICATION NAME]. He stated the burn was second degree and he described it as being red with no blisters, vesicles, pus, or fluid formation. On 12/14/2017 at 2:36 PM, CNA #13 stated in an interview, he was assigned to the resident on 11/11/2017 when the incident occurred but he was not aware at that time that CNA #7 gave the resident a hot towel or that she sustained a burn. He stated after the incident occurred at 3 AM, he never spoke to the resident again during the shift because she was asleep. He stated he documented that he completed a skin check on the resident on 11/11/2017 at 6:39 AM, and he did not complete the skin check. He stated CNA #7 provided the resident's care so she would have done the skin check and since she did not tell him the resident had any new skin issues, he documented that she had no new skin issues. He stated since he was the permanent CNA on the unit, he documented on every resident even the ones that CNA #7 provided care for. On 12/14/2017 at 3:25 PM, RN #14 stated in an interview, she was working on 11/11/2017 at 3 AM when CNA #7 answered the resident's call bell and gave her a hot towel but she was not aware that occurred. She stated she was notified of the incident by the resident on 11/11/2017 a little before midnight. She looked at the resident's leg and saw a brownish and darkened area that was about 7 cm x 3 cm. The resident said it did not hurt, she did not call the physician, and she applied [MEDICATION NAME] to the burn. She stated she documented in error in her statement that she applied petroleum jelly to the resident's burn. She stated she left the facility at 7 AM on 11/12/2017 and told the day RN (RN #9) about the burn. She returned to the facility at 7 PM on 11/12/2017 and on 11/13/2017 at 7:30 AM when the physician was doing rounds, she told him about the burn. She stated she now realized that she should not have waited to notify the physician and should not have applied a treatment without an order. On 12/28/2017 at 8:45 AM, RN Supervisor #17 stated in an interview, on 11/11/2017, she was on the unit and smelled what she thought was burning popcorn. She stated at that time, CNA #7 told her she warmed up a towel in the microwave for a resident. She stated she told CNA #7 they were not allowed to put anything hot on residents and CNA #7 did not tell her that she had already done it. She stated she knew CNA #7 previously and knew she was a good CNA so she assumed that CNA #7 followed her directive and did not place a hot towel on a resident. 10NYCRR415.12

Plan of Correction: ApprovedJanuary 23, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective action(s) will be accomplished for the resident found to have been affected by deficient practice?
Resident #556 is no longer an active resident of the facility.
Upon physician notification of non-pressure related skin concern resident was assessed by medical professional and treatment orders were initiated in accordance with professional standards of practice. Upon discharge area was healed without complications.
How will we identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Full house audit will be conducted by licensed nursing personnel completing a skin check to identify all residents who have a non-pressure trauma related skin concern requiring medical care and treatment. Any residents noted to have non-pressure skin related concern(s) will have a medical record review completed to ensure appropriate medical notification and active treatment order in place in accordance with professional standards of practice.
What measures will be put in place or what systemic changes will you make to ensure that the deficient practice will not recur?
Warm moist compress policy and procedure reviewed for any necessary changes.
All nursing personnel re-educated on the application of warm moist compress.
Licensed nursing personnel re-educated on the need to obtain physician order [REDACTED].
All nursing personnel will be educated on the reporting requirements and timeliness of reporting skin concerns.
All nursing personnel will be re-educated on the documentation of new skin issues and the personnel that is responsible for such documentation.
All new nursing personnel will be educated on the above upon hire and annually thereafter.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
Audit tool will be developed to monitor non-pressure trauma related skin concerns that require treatment and care in accordance with professional standards to ensure appropriate notification and active treatment order in place. This audit will be conducted monthly for 3 months by the nurse managers to achieve 90-100% compliance; then quarterly thereafter for a period of 1 year. If sustained compliance is not achieved, auditing will continue. Audit will be reported to the Quality Assessment and Assurance Committee on a quarterly basis throughout the auditing period.
Responsible Person:
Director of Nursing

FF11 483.10(c)(6)(8)(g)(12)(i)-(v):REQUEST/REFUSE/DSCNTNUE TRMNT;FORMLTE ADV DIR

REGULATION: §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. §483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate. §483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law. (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.

Scope: Isolated
Severity: Actual harm has occurred
Citation date: January 8, 2018
Corrected date: March 8, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification and abbreviated surveys (NY 729), the facility did not ensure 1 of 38 residents reviewed for advance directives (Resident #557) had their advance directives honored. Specifically, Resident #557 was resuscitated despite a do not resuscitate (DNR, withhold cardiopulmonary resuscitation, CPR, when the heart stops beating) order in the resident's medical record. This resulted in actual harm for Resident #557 that is not immediate jeopardy. Findings include: The facility's Advance Directives policy, updated ,[DATE], documented it was the right of residents to establish advance directives. Advance directives were to be discussed on admission and verbal physician orders [REDACTED]. Resident #557 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident was admitted from the hospital where he was diagnosed with [REDACTED]. The resident signed a Medical Orders for Life-Sustaining Treatment (MOLST) on [DATE] at 5:05 PM documenting that he wanted a do not resuscitate (DNR) order. The form was also signed by registered nurse (RN) #1. A verbal physician's orders [REDACTED].#2) documented the resident had a DNR order. The attending physician signed the verbal order at 7:25 PM. The [DATE] RN #1's progress note at 9:20 PM, documented at 8:50 PM, the resident was found unresponsive. Cardiopulmonary resuscitation (CPR) was started, one shock was administered via the AED (automated defibrillator, device to shock the heart), and the resident resumed breathing on his own. The physician and paramedics were called and at 9 PM, the resident was transported to the hospital. The [DATE] nursing progress notes documented: - At 2 AM, the hospital reported the resident requested to be extubated (removed from artificial ventilation) and sent back to the facility on comfort care only. Upon return to the facility, the resident complained of the worst possible chest pain and was medicated. - At 6:22 AM, the resident was sent back to the hospital as chest pain was uncontrolled by medication. - At 6:50 AM, the resident expired at the hospital. The facility's investigation dated [DATE] and signed by Assistant Director of Nursing (ADON) ADON #5 documented: - The resident was alert and oriented, able to make health care decisions, and discussed advance directive wishes with RN #1 shortly after admission. The resident and RN #1 signed the MOLST for a DNR. - Certified nurse aide (CNA) #15 found the resident unresponsive, RN #1 responded to the room, and directed staff to start CPR. - Six staff members performed CPR on the resident throughout the 8 minutes until spontaneous pulse and respirations resumed. - RN #1 made the decision to start CPR and stated she thought the resident's advance directives were unclear as no documentation of his wishes came with him from the hospital, the MOLST was not yet signed by the physician, and she had not performed the second check of the resident's orders in the electronic medical record at the time that he was found unresponsive. - RN Supervisor #3's statement documented when she arrived at the room, CPR was in progress. She saw the resident's MOLST documented DNR but saw it did not have a second witness signature or the physician's signature. She circled DNR status on the hospital transfer form and wrote MOLST not completed on the form. - RN Supervisor #4's statement documented when she entered the room, CPR was in progress. She attempted to obtain information about the resident and noticed the MOLST was not signed by the physician, did not have a second witness signature, and she assisted with CPR. On [DATE] at 11:46 AM, RN Manager #2 stated in an interview, on the day the resident was admitted , she reviewed the MOLST that the resident completed with RN #1 and entered the DNR order into the medical record. She stated she left the facility at a little after 6 PM and when she left, she told RN #1 she obtained the resident's orders from the physician and entered them into the electronic medical record. RN Manager #2 stated the resident expressed his wish for a DNR and those wishes should have been honored. On [DATE] at 12:53 PM, RN #1 stated in an interview: - She completed the MOLST with the resident when he was admitted . The resident told her he just had heart surgery and the hospital required him to be a full code for the surgery but that he wanted to resume his DNR order at the facility. The resident signed the MOLST and so did RN #1. RN Manager #2 entered the DNR order into the medical record. - As she was completing paperwork, someone told her the resident was not responsive. She assessed the resident, tried to arouse him, and when he did not arouse she realized it was the new admission and he had just had cardiac surgery. She had staff start CPR. - She started CPR because she thought the resident wanted to live. She stated if he did not want to live, he would not have had a cardiac procedure with stents placed a few days prior. - She also intervened because the resident looked like he was in pain and she wanted to help him. - She did not check his MOLST and did not remember completing a MOLST with him earlier in the shift. - She stated time was heart and brain muscle and she could not stop to check paperwork when someone needed CPR. On [DATE] at 3:47 PM, RN Supervisor #3 stated in an interview, when she got to the resident's room, CPR was in progress and because there were so many people in the room, she went to the desk to get the paperwork ready for the hospital. She saw the resident's MOLST on the desk with RN #1 and the resident's signatures and noticed the MOLST was not signed by the physician or a second witness. She stated RN #1 told her the resident rescinded his DNR for the cardiac surgery, she completed a new MOLST with him, and she had not entered his orders into the electronic medical record yet. RN Supervisor #3 stated since the MOLST was not signed by 2 witnesses or the physician, she did not know if it was valid. She stated she did not send the MOLST to the hospital with the resident as it was incomplete and she was not aware the resident had an order for [REDACTED]. On [DATE] at 4:20 PM, RN Supervisor #4 stated in an interview, she responded to the unit when the code was called and tried to determine the resident's code status. She was told by RN #1 that she was in the process of working on the resident's admission, the orders had not been double checked yet, and the MOLST was not witnessed or signed. She stated RN #1 did not tell her that she did the MOLST with the resident a few hours before and RN #4 did not know the resident had an order for [REDACTED]. On [DATE] at 2 PM, the attending physician stated in an interview, he saw the resident about an hour after admission. The resident had a cardiac procedure that went well and he was sitting up talking to the physician. He did not talk to the resident about advance directives on admission but knew the resident signed a MOLST later that evening. He stated he signed the DNR order entered by RN Manager #2 as he knew the resident was alert and oriented and able to make advance directive decisions. He stated the resident expressed his wish for DNR so that should have been honored and he did not believe that the 2 witness signatures were needed on the MOLST since the resident was able to state his wishes. The attending physician stated when he was called, the resident was breathing on his own and he did not immediately recall the DNR order. He stated the next morning at around 3 AM, the resident wanted to come back to the facility on comfort care so he gave the order and when he returned, they could not control his pain, and he was sent back to the hospital and expired. 10NYCRR 415.3(e)(1)(ii)

Plan of Correction: ApprovedJanuary 23, 2018

What corrective action(s) will be accomplished for the resident found to have been affected by deficient practice?
Resident #557 is no longer an active resident of the facility.
Director of Nursing, Administrator and Physician reviewed the details surrounding the occurrence and completed a medical record review, including a review of the Medical Orders for Life-Sustaining Treatment (MOLST) and physician?s orders for Resident #557.
How will we identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Full house audit to be completed to review to ensure that each resident has an advanced directive in place, and that the advance directive accurately reflects the wishes of the resident. The facility will ensure residents do not receive advance directive treatment that conflicts with their wishes by providing education to all nursing staff members as well as all staff who have the potential to alter a document relating to the resident's advance directive wishes on the policies and procedures related to advanced directives.
What measures will be put in place or what systemic changes will you make to ensure that the deficient practice will not recur?
Advanced Directive policies and procedures reviewed for any necessary revisions.
All nursing staff as well as all staff who have the potential to alter a document relating to the resident's advance directive wishes will receive education on the policies and procedures related to Advanced Directives, including MOLST completion, and the need to ascertain the wishes of the resident regarding advanced directives prior to initiating or withholding resuscitation upon hire and annually thereafter.
All new nursing staff as well as all staff who have the potential to alter a document relating to the resident's advance directive wishes will receive education on the policies and procedures related to Advanced Directives, including MOLST completion, and the need to ascertain the wishes of the resident regarding advanced directives prior to initiating or withholding resuscitation upon hire.
All residents with a DNR order will be reviewed to ensure all procedures related to non-resuscitation status are in place (i.e., physician orders, MOLST, care plan, resident profile).
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
Audit tool will be developed to monitor to ensure all procedures related to non-resuscitation status are in place (i.e., physician orders, MOLST, care plan, and resident profile). This audit will be conducted by nursing upon admission, re-admission and change of advanced directive status for 3 months to achieve 90-100% compliance; then quarterly thereafter for a period of 1 year. If sustained compliance is not achieved, auditing will continue. Audit will be reported to the Quality Assessment and Assurance Committee on a quarterly basis throughout the auditing period.
Responsible Person:
Director of Nursing

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

REGULATION: Electrical Systems - Essential Electric System Alarm Annunciator A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator. 6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99)

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 8, 2018
Corrected date: February 23, 2018

Citation Details

Based on observations and interview during the recertification survey, the facility did not ensure the emergency generator remote annunciator was properly installed for the generator. Specifically, the remotely installed alarm annunciator for the emergency generator was not located in an area that had 24-hour staff coverage. Findings include: During an interview on 1/3/18 at 9:35 AM with the Director of Plant Operations, he stated the master mason generator annunciator panel was located in the maintenance shop. The maintenance department has two shifts 8:00 AM to 4:00 PM, and 3:00 PM to 11 PM. The third shift between 11 PM and 8 AM is covered by a boiler operator/maintenance mechanic who would not be present in the maintenance shop during the entire shift. During an interview on 1/4/2018 at 1:47 PM with maintenance mechanic #1, he stated he checked the annunciator twice per shift, and had just worked the third shift that night. There was only one operator per 8-hour shift, and has never heard the annunciator go off in the ten years he had been employed at the facility. There were not maintenance staff on duty during the overnight shift. On 1/4/2018 at 2:00 PM, a surveyor in the maintenance shop observed a generator remote annunciator panel. During an interview on 1/4/2018 at 2:04 PM with the Plant Operations Supervisor, he stated from 3:00 PM to 11 PM there is only one maintenance person in the facility. The clinical labs and the education office next to the maintenance shop are not manned after 4:00 PM. 2012 NFPA 99: 6.4.1.1.17 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedFebruary 6, 2018

What corrective action(s) will be accomplished for the Area found to have been affected by deficient practice?
The emergency annunciator panel for the Master(NAME)generator is being relocated from the maintenance shop to the Health Facility front desk which is manned 24/7/365 to ensure 24 hour staff coverage in accordance with NFPA 99.
How will we identify other areas of having the potential to be affected by the same deficient practice and what corrective action will be taken?
There are no other affected areas; K pod generator Annunciator panel is already located at the front desk of the Health facility to ensure 24 hour staff coverage.
What measures will be put in place or what systemic changes will you make to ensure that the deficient practice will not recur?
The relocation of the emergency annunciator panel for the Master(NAME)generator will be a permanent change. Front desk staff will be educated on the procedures related to the emergency annunciator panel.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
The emergency annunciator panel for the Master(NAME)and K-pod generators will be monitored 24/7/365 at their front desk location. Any issues will be reported to Plant Operations on a daily basis. Audit will be completed by Plant Operations on a monthly basis to ensure proper placement of the emergency annunciator panel.
Responsible Person:
Director of Plant Operations

K307 NFPA 101:EMERGENCY LIGHTING

REGULATION: Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1

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

Citation Details

Based on record review and interview conducted during the recertification survey, the facility's emergency lighting was not maintained for 1 of 1 generator rooms. Specifically, the generator room did not contain a battery-operated emergency light. Findings include: On 1/4/2018 at 10:45 AM, a surveyor in the generator room observed there was no battery-operated emergency light. During an interview on 1/4/2017 at 10:45 AM, the Director of Plant Operations stated the generator room lacked a battery-operated emergency light. 2012 NFPA 101: 19.2.9.1, 7.9 10NYCRR 415.29(a)(1&2), 711.2(a)(1)

Plan of Correction: ApprovedFebruary 6, 2018

What corrective action(s) will be accomplished for the Area found to have been affected by deficient practice?
Battery-operated emergency lighting has been installed for the generator room.
How will we identify other areas of having the potential to be affected by the same deficient practice and what corrective action will be taken?
There are no other areas within the health facility that have the potential to be affected by this same deficient practice.
What measures will be put in place or what systemic changes will you make to ensure that the deficient practice will not recur?
Battery-operated emergency light for the generator room will be put on PM Worx program schedule and will be inspected monthly and documented. Plant Operations staff will be educated on the emergency lighting system.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
Battery-operated emergency light for the generator room will be audited monthly by being placed onto PM Worx program schedule and inspected monthly by the plant operations department and documented.
Responsible Person:
Director of Plant Operations

K307 NFPA 101:EVACUATION AND RELOCATION PLAN

REGULATION: Evacuation and Relocation Plan There is a written plan for the protection of all patients and for their evacuation in the event of an emergency. Employees are periodically instructed and kept informed with their duties under the plan, and a copy of the plan is readily available with telephone operator or with security. The plan addresses the basic response required of staff per 18/19.7.2.1.2 and provides for all of the fire safety plan components per 18/19.2.2. 18.7.1.1 through 18.7.1.3, 18.7.2.1.2, 18.7.2.2, 18.7.2.3, 19.7.1.1 through 19.7.1.3, 19.7.2.1.2, 19.7.2.2, 19.7.2.3

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 8, 2018
Corrected date: February 28, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification and abbreviated surveys (NY 681) the facility did not ensure there was a written plan for the protection of all residents and for their evacuation in the event of an emergency for 1 of 37 sampled residents (Resident #556) residing on 1 of 23 households (Saratoga). Specifically, there was a smoke fire in Resident #556's room and the facility did not ensure the fire plan was activated and followed. Findings include: The facility's mandatory Fire Plan training dated (YEAR) documented the facility followed the fire procedure of R.A.C.E. (rescue, alarm, contain, and evacuate) and documented when an alarm sounded for a fire drill or a real fire staff were to follow R.A.C.E. The training material did not include documentation as to when staff members should activate the fire alarm on their own. The facility's Emergency Action Plan policy dated 3/16/2012 documented when a staff member located a fire or the fire lantern (used for drills) they were to implement R.A.C.E. There was no further documentation in the policy as to when staff members should activate the fire alarm. Resident #556 was admitted to the Saratoga household at the facility on 11/2/2017 following a revision of a total right hip. The resident was cognitively intact per the 11/9/2017 Minimum Data Set (MDS) assessment. The facility's investigative summary dated 11/17/2017 and signed by Assistant Director of Nursing (ADON) #5 documented the resident sustained [REDACTED]. Included with the investigation was the 11/16/2017 fire alarm inspection company's report which documented the smoke detector in the resident's room was inspected following a smoke fire in the room and the system was operational. Staff statements with the investigation included: - Certified nurse aide (CNA) #7's statements dated 11/12/2017 and 11/15/2017 documented she warmed a towel in the microwave to give to the resident and she did not realize the towel was hot until she smelled a burning smell in the hallway. She documented the resident's comforter was burned and she placed the burned comforter in the laundry room. - The resident's statement dated 11/15/2017, written by registered nurse (RN) Manager #2 documented the CNA gave the resident a warm towel and the resident placed it on top of the sheet between her leg and the comforter. A few minutes later, the resident smelled something burning and rang her call bell. The CNA threw the towel in the sink and ran it under cold water. The resident requested new sheets and a new comforter because hers were damaged and the CNA provided them. - Registered nurse (RN) #7's statement dated 11/17/2017 documented she smelled something burning on the unit on 11/11/2017. The CNA told her it was a towel that she put in the microwave. RN #7 also documented the unit had a bad smell of something that may have been burning so she assessed the microwave for any potential fires and since she did not find anything, she did not think there was a reason to pull the fire alarm or contact the fire department. On 12/11/2017 at 9:15 AM, CNA #7 stated in an interview, on 11/11/2017 at around 3 AM, she warmed a towel up in the dryer and when it was not warm enough, she warmed it up in the microwave for about 1-2 minutes and gave it to the resident. She stated she did not realize the towel was hot until she went back into the hall and smelled a burning smell. A few minutes later, the resident rang her call bell and said the towel burned the comforter. When she gave the resident the towel it was white and when she got the towel back from the resident, it was brown and warm. She stated she ran the towel under water because she thought the towel would melt the plastic in the garbage can. She stated the resident's comforter had a hole in it and so did the sheets so she changed the comforter and put the burned one in the laundry room on the unit. She stated she smelled the burning in the resident's room and in the hallway and did not consider pulling the fire alarm. On 12/14/2017 at 12 PM, Maintenance Supervisor #11 stated in an interview, if staff members saw flames or smelled smoke, they should manually activate the fire alarm and follow the facility's fire policy. On 12/14/2017 at 2:30 PM, the surveyor observed and measured the resident's comforter. The comforter had 2 burn holes in it. The first hole burned through all layers of the blanket and measured 2.75 inches across x 4 inches long at the longest portion. There were brown marks on the underside of the comforter where the hole was. The second hole burned through the top layer of the comforter and measured 1-inch x 1-inch. There were brown marks surrounding the burn hole on the top and underside of the comforter. On 12/14/2017 at 2:36 PM, CNA #13 stated in an interview, on 11/11/2017 he returned to the unit from his break at 3 AM and smelled a burning smell throughout the unit. He stated the smell stunk the whole household like something was on fire. He did not ask anyone if they knew what the smell was but he checked the unit and when he did not find any fire, he proceeded with his work. He stated he did not know when he should manually activate the fire alarm. On 12/28/2017 at 8:45 AM, RN Supervisor #17 stated in an interview, on 11/11/2017, she was on the unit and smelled what she thought was burning popcorn. She stated at that time, CNA #7 told her she warmed up a towel in the microwave for a resident. She stated because of the smell she went and looked at the microwave and dryer and did not see anything that could be burning. She stated she did not think at that time there was a reason to activate the fire alarm. On 1/8/2018 at 1:35 PM, the Director of Safety was interviewed and stated he completed in person orientation with newly hired employees and during orientation, he told the staff members to manually pull the fire alarm if they smelled smoke, saw smoke, saw any sign of fire, or felt a hot door. He stated he did not know why the unit staff did not pull the fire alarm the night of the resident's incident but stated if staff smelled smoke, they should pull the fire alarm. 2012 NFPA 101: 19.7.2.3 2011 NFPA 25 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedFebruary 6, 2018

What corrective action(s) will be accomplished for the resident found to have been affected by deficient practice?
Resident #556 is no longer an active resident in the facility. Certified Nurse Aid (CNA) #7 had completed her mandatory annual in-service on the facility?s fire plan. CNA #7 is no longer an active employee of the facility.
How will we identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All residents have the potential to be affected by the same deficient practice. Training materials have been updated and all facility staff will receive education on the Fire Plan.
What measures will be put in place or what systemic changes will you make to ensure that the deficient practice will not recur?
Facility?s fire plan included in the Emergency Action Plan policy has been revised to include when staff members should activate the fire alarm.
Training material has been updated to include documentation as to when staff members should activate the fire alarm on their own.
All facility staff are in the process of receiving education on the updated Emergency Action Plan that has been updated to include when they should activate the fire alarm on their own. This education will also be incorporated into the facility mandatory in services that are provided on an annual basis. Audit will be completed by the Education Department to ensure that facility staff have successfully completed the education.
All new facility staff will be educated on the above items during their initial orientation period and annually thereafter in accordance with the facility mandatory in service schedule.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
Fire drills will continue to be conducted and documented in accordance to code requirements. Training on R.A.C.E. will continue to be incorporated into the fire drill, and will include when staff should activate the fire alarm on their own.
Audit will be conducted on each incident involving need for activation of the fire alarm to ensure the fire plan was properly activated and followed. This audit will be completed monthly for a total of 1 year to ensure 90-100% compliance. If sustained compliance is not achieved, auditing will continue. Audit will be reported to the Quality Assurance Committee on a monthly basis throughout the auditing period.
Responsible Person:
Director of Safety & Security

K307 NFPA 101:HAZARDOUS AREAS - ENCLOSURE

REGULATION: Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 8, 2018
Corrected date: March 1, 2018

Citation Details

Based on observation and interview during the recertification survey, the facility did not ensure hazardous areas were maintained for one isolated room (pool room door/frame). Specifically, the pool room measured over 50 square feet in size, housed combustible items and the pool room doors and frame were not fire rated. Findings include: On 1/3/2018 at 11:43 AM, a surveyor observed a large quantity of combustible items stored in the pool room which measured over 50 square feet. The items included but were not limited to 79 wooden cabinets, a few cloth cubicle dividers, 1 mattress and 3 wheelchairs. This made the pool room a hazardous area. The double doors to the room and the door frame were not fire rated. During an interview on 1/4/2017 at 5:00 PM, the Director of Plant Operations stated the pool room was being used for storage while maintenance within the facility was in transition. 2012 NFPA 101 19.3.2.1 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedFebruary 6, 2018

What corrective action(s) will be accomplished for the resident found to have been affected by deficient practice?
The combustible items being housed in the pool room will be removed and stored in proper location.
How will we identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
There are no other Combustible Storage Rooms within the Health facility that are creating a hazardous area.
What measures will be put in place or what systemic changes will you make to ensure that the deficient practice will not recur?
Plant Operations, Housekeeping, Therapy and Nursing will identify all combustible items that are being housed in the pool room and ensure that all combustible items are removed and properly stored.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
Audit will be conducted by Director of Safety & Security on a monthly basis for a period of 1 year to ensure 100% compliance with the pool room not being used to house combustible items. If sustained compliance is not achieved, auditing will continue. Audit will be reported to the Quality Assurance Committee on a monthly basis throughout the auditing period.
Responsible Person:
Director of Safety & Security

HOSPITAL CAH AND LTC EMERGENCY POWER

REGULATION: (e) Emergency and standby power systems. The hospital must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section and in the policies and procedures plan set forth in paragraphs (b)(1)(i) and (ii) of this section. §483.73(e), §485.625(e) (e) Emergency and standby power systems. The [LTC facility and the CAH] must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section. §482.15(e)(1), §483.73(e)(1), §485.625(e)(1) Emergency generator location. The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated. 482.15(e)(2), §483.73(e)(2), §485.625(e)(2) Emergency generator inspection and testing. The [hospital, CAH and LTC facility] must implement the emergency power system inspection, testing, and maintenance requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code. 482.15(e)(3), §483.73(e)(3), §485.625(e)(3) Emergency generator fuel. [Hospitals, CAHs and LTC facilities] that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency, unless it evacuates. *[For hospitals at §482.15(h), LTC at §483.73(g), and CAHs §485.625(g):] The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may obtain the material from the sources listed below. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html. If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes. (1) National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02169, www.nfpa.org, 1.617.770.3000. (i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11, 2011. (ii) Technical interim amendment (TIA) 12-2 to NFPA 99, issued August 11, 2011. (iii) TIA 12-3 to NFPA 99, issued August 9, 2012. (iv) TIA 12-4 to NFPA 99, issued March 7, 2013. (v) TIA 12-5 to NFPA 99, issued August 1, 2013. (vi) TIA 12-6 to NFPA 99, issued March 3, 2014. (vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011. (viii) TIA 12-1 to NFPA 101, issued August 11, 2011. (ix) TIA 12-2 to NFPA 101, issued October 30, 2012. (x) TIA 12-3 to NFPA 101, issued October 22, 2013. (xi) TIA 12-4 to NFPA 101, issued October 22, 2013. (xiii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 8, 2018
Corrected date: March 8, 2018

Citation Details

Based on observation and interview during an Emergency Preparedness (EP) survey, 1 of 2 emergency generators (master mason generator) located within the facility was not located in accordance with NFPA (National Fire Protection Association) 99. Specifically, the remote annunciator panel for the master mason generator was not located within an area of the facility that had 24-hour staff coverage. Findings include: When interviewed on 1/3/18 at 9:35 AM with the Director of Plant Operations, he stated the master mason generator annunciator panel was located in the maintenance shop. The maintenance department has two shifts 8:00 AM to 4:00 PM, and 3:00 PM to 11:00 PM. The third shift between 11 PM and 8 AM is covered by a boiler operator/maintenance mechanic who would not be present in the maintenance shop during the entire shift. When interviewed on 1/4/2018 at 1:47 PM with maintenance mechanic #1, he stated he checked the annunciator twice per shift, and had just worked the third shift that night. There was only one operator per 8-hour shift, and he had never heard the annunciator go off in the ten years he had been employed at the facility. There were not maintenance staff on duty during the overnight shift. When observed on 1/4/2018 at 2:00 PM, the remote annunciator panel for the master mason generator was located within the maintenance shop on the basement level of the facility. During an interview on 1/4/2018 at 2:04 PM with the Plant Operations Supervisor, he stated from 3:00 PM to 11:00 PM there is only one maintenance person in the facility. The clinical labs and the education office next to the maintenance shop are not manned after 4:00 PM. 42 CFR 483.73(e)(1) 2012 NFPA 99: 6.4.1.1.17

Plan of Correction: ApprovedFebruary 6, 2018

What corrective action(s) will be accomplished for the Area found to have been affected by deficient practice?
The emergency annunciator panel for the Master(NAME)generator is being relocated from the maintenance shop to the Health Facility front desk which is manned 24/7/365 to ensure 24 hour staff coverage in accordance with NFPA 99.
How will we identify other areas of having the potential to be affected by the same deficient practice and what corrective action will be taken?
There are no other affected areas; K pod generator Annunciator panel is already located at the front desk of the Health facility to ensure 24 hour staff coverage.
What measures will be put in place or what systemic changes will you make to ensure that the deficient practice will not recur?
The relocation of the emergency annunciator panel for the Master(NAME)generator will be a permanent change. Front desk staff will be educated on the procedures related to the emergency annunciator panels.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
The emergency annunciator panel for the Master(NAME)and K-pod generators will be monitored 24/7/365 at their front desk location. Any issues will be reported to Plant Operations on a daily basis. Audit will be completed by Plant Operations on a monthly basis to ensure proper placement of emergency annunciator panel.
Responsible Person:
Director of Plant Operations

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: January 8, 2018
Corrected date: February 23, 2018

Citation Details

Based on observation and interview during the recertification survey, the facility did not ensure the building was protected throughout by an approved automatic sprinkler system, in accordance with National Fire Protection Association (NFPA) 13, Standard for the Installation of Sprinkler Systems, for 1 isolated area (housekeeping storage room). Specifically, the housekeeping storage room contained both quick-response and standard response sprinkler heads where all sprinklers within a compartment shall be quick-response sprinkler heads. Findings include: On 1/3/2018 at 9:50 AM, a surveyor in the housekeeping storage room observed 1 quick-response sprinkler head and 4 standard response sprinkler heads. During an interview on 1/3/2017 at 9:50 PM, the Director of Plant Operations stated only the third-party sprinkler company changes the sprinkler heads in the facility. He was not aware quick-response sprinkler heads and standard response sprinkler heads could not be located within the same room/area. 2012 NFPA 101 19.3.5.1, 9.7.1.1 2010 NFPA 13 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedFebruary 6, 2018

What corrective action(s) will be accomplished for the Area found to have been affected by deficient practice?
All sprinkler heads in the Housekeeping Storage Room have been changed to quick-response sprinkler heads by Metallo Sprinkler Company.
How will we identify other areas of having the potential to be affected by the same deficient practice and what corrective action will be taken?
Sprinkler Vendor and Plant Operations staff will review all areas for compliance.
What measures will be put in place or what systemic changes will you make to ensure that the deficient practice will not recur?
All sprinkler Inspections are done 3rd party on a quarterly basis. Any reports of deficiencies will be reported to Plant Operations and measures will be taken immediately to ensure compliance. A full visual of all sprinklers is conducted annually. Education will be provided to Plant Operations staff on sprinkler head identification and requirements.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
Audit will be completed by Plant Operations on a quarterly basis to ensure compliance with quarterly sprinkler inspections.
Responsible Person:
Director of Plant Operations

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: January 8, 2018
Corrected date: February 8, 2018

Citation Details

Based on observation and interview during the recertification survey, the facility did not ensure the building's automatic sprinkler system was maintained in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems, for one isolated room (resident storage room). Specifically, the resident storage room had sections of ceiling tile missing that would allow smoke to rise past the sprinkler heads, not allowing the sprinkler heads to function as designed. Findings include: On 1/2/2018 at 2:07 PM, a surveyor in the resident storage room observed over thirty 2-foot x 2-foot ceiling tiles missing from the suspended ceiling. Multiple other sized ceiling tiles were also missing. These missing ceiling tiles would allow smoke to rise past the sprinkler heads, not allowing the sprinkler heads to function as designed. During an interview on 1/4/2017 at 4:52 PM, the Director of Plant Operations stated in the past, the Fire Marshall and previous surveyors have been in this room and no one stated there were issues with missing ceiling tiles. He stated this room has had been missing ceiling tiles since he was hired thirteen years ago. 2012 NFPA 101: 19.3.5.1, 9.7.5 2011 NFPA 25 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedFebruary 6, 2018

What corrective action(s) will be accomplished for the Area found to have been affected by deficient practice?
All missing ceiling tiles in resident storage area have been replaced, a bulkhead has been built around the affected area where sprinkler heads protrude through ceiling and where sprinkler heads wash the roof area in which the area was designed not to have a drop ceiling.
How will we identify other areas of having the potential to be affected by the same deficient practice and what corrective action will be taken?
There are no other areas within the Health facility that have the potential to be affected by this same deficient practice.
What measures will be put in place or what systemic changes will you make to ensure that the deficient practice will not recur?
The facility will continue with 3rd party sprinkler inspections. Any deficiencies will be noted during our 3rd party sprinkler inspection process. Plant Operations staff will be educated on proper placement of ceiling tiles.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
Audit will be completed by Plant Operations on a quarterly basis to ensure proper placement of ceiling tiles. The facility will continue with 3rd party sprinkler inspections. Any deficiencies will be noted during our 3rd party sprinkler inspection process.
Responsible Person:
Director of Plant Operations

K307 NFPA 101:VERTICAL OPENINGS - ENCLOSURE

REGULATION: Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 8, 2018
Corrected date: February 23, 2018

Citation Details

Based on observation and interview during the recertification survey, the facility did not ensure that all vertical openings were properly enclosed with construction having a fire resistance rating of at least one hour for 1 isolated area (BG34 communications room). Specifically, the BG34 communication room had an unsealed penetration. Findings include: On 1/3/2018 at 11:52 AM, a surveyor in the BG34 communication room observed a 4-inch empty conduit passing into the floor below. During an interview on 1/4/2017 at 4:52 PM, the Director of Plant Operations stated the 4-inch conduit in the BG34 communications room was a spare conduit and was not aware it was not properly sealed. 2012 NFPA 101: 19.3.1, 8.6.2 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedFebruary 6, 2018

What corrective action(s) will be accomplished for the Area found to have been affected by deficient practice?
The vertical opening in Communications Room (BG34) has been properly sealed according to good smoke barrier practices.
How will we identify other areas of having the potential to be affected by the same deficient practice and what corrective action will be taken?
All possible affected areas throughout the facility have been surveyed for similar issues, any suspicious areas were resealed.
What measures will be put in place or what systemic changes will you make to ensure that the deficient practice will not recur?
Educate staff and contractors on reporting any suspected breach in smoke barriers and report such to Plant Operations. All suspected breaches in smoke barriers will be properly sealed.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
Audit will be completed by Plant Operations on a bi-annual basis of all areas i.e., Electrical Closets, Communication Rooms to ensure there are no breaches. This will be monitored, recorded and delegated through the PM Worx program.
Responsible Person:
Director of Plant Operations