Quantum Rehabilitation and Nursing LLC
October 25, 2017 Certification Survey

Standard Health Citations

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 25, 2017
Corrected date: December 22, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the recertification survey the facility did not ensure that the Minimum Data Set (MDS) Assessments accurately reflected the current status of each resident. This was evident for 2 (Resident # 17 and # 132) of 32 Stage 2 sampled residents reviewed for MDS accuracy. Specifically, 1) the MDS inaccurately documented that Resident # 17 had no natural teeth or tooth fragments and 2) Resident # 132 was inaccurately assessed as continent of urine. The findings are: 1) Resident # 17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] documented the resident had short and long term memory loss and had severely impaired cognition. The annual MDS dated [DATE] documented that the resident had no natural teeth or tooth fragments. Dental Consultations dated 4/26/16 and 4/11/17 documented that the resident had many natural teeth present. The Registered Nurse (RN) MDS Coordinator was interviewed on 10/24/17 at 9:15 AM and stated that she examined the resident on 10/24/17 and determined the resident had natural teeth and root fragments. The RN stated that the MDS dated [DATE] was not accurate and should have documented that the resident had teeth and root fragments. The Director of Nursing Services (DNS) was interviewed on 10/25/17 at 7:20 AM and stated that the dental section of the MDS was incorrect.
2) Resident # 132 was re- admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. The 7/3/17 Admission MDS assessment documented the resident was always continent of urine. The quarterly 9/20/17 MDS assessment documented the resident was always incontinent of urine. The admission assessment dated [DATE], completed by the Registered Nurse (RN), documented that the resident was incontinent of urine. A Comprehensive Care Plan dated 9/28/16 assessed the resident with incontinence of urine. Goals and interventions were in place to address the resident's incontinence. The Certified nursing assistant accountability record (CNAAR) was reviewed for the assessment period for the 7/3/17 MDS assessment. The CNAAR revealed the resident had 13 incontinent episodes and 1 continent episode of urine within 7 days of the assessment prior to 7/3/17. The bladder assessment dated [DATE] documented the resident was always incontinent of urine. The MDS RN was interviewed on 10/23/17 at 11:00 AM and stated the 7/3/17 MDS was incorrect. The MDS should have documented the resident was always incontinent of urine. 415.11(b)

Plan of Correction: ApprovedNovember 17, 2017

1. The MDS assessments for Residents #17 and 132 were corrected and resubmitted immediately following the finding.
2. An audit will be conducted of all active patients for MDS sections H and L and any findings will be corrected and resubmitted immediately.
3. The MDS assessors identified to have had made the input error are no longer with the facility so no counseling was able to be completed. The DNS reviewed the policy for MDS assessment with the MDS coordinator and no changes were necessary. All MDS assessors will be reinserviced with regard to the appropriate procedure for assessing a patient for sections H and L of the MDS with emphasis on ensuring accuracy of reporting what is reflected in the patients medical record.
4. An audit tool will be created and utilized to monitor the accuracy of sections H and L of the MDS. The ADN or her designee will monitor 10% of the MDS books weekly for accuracy of sections H and L of the MDS and report to the QAPI committee monthly for three months for evaluation and follow up as indicated and necessary. At the end of the three month period, the QAPI committee will determine the need of ongoing auditing or additional corrective actions.
5. The person responsible will be the MDS Coordinator and the date of completions will be 12/22/17.

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

REGULATION: The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-- (2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and (3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. (g) Labeling of Drugs and Biologicals. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. (h) Storage of Drugs and Biologicals. (1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. (2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 25, 2017
Corrected date: December 22, 2017

Citation Details

Based on observation and interview conducted during the recertification survey, the facility did not ensure that medications were not used beyond their expiration dates. Specifically, expired medications were found in the medication storage area in 1 of 2 facility units (Unit 2) and were not disposed per manufacturer's recommendations. The finding is: The facility medication policy stated that expired, discontinued and /or contaminated medications will be removed from the mediation storage areas and disposed of in accordance with facility policy and that medication will be stored in a manner that maintains the integrity of the product to ensure the safety of the residents. On 10/18/17 at 11:00 AM the 2nd floor emergency medication box was observed with 4 tablets of Lisinopril that expired on 7/12/17. The Registered Nurse charge nurse was interviewed and stated that the expired medication should not have been stored in the box. The Pharmacist was interviewed on 10/25/17 at 10:30 AM and stated that it was an oversight that the medication was stored on the unit and the medication should have been removed from the box prior to the expiration of the medication. 415.18(d)

Plan of Correction: ApprovedNovember 17, 2017

1. The expired medication was removed immediately upon identification.
2. All emergency boxes were reviewed to ensure that no other medications were expired, no other findings identified.
3. A review of the policy and procedure for the emergency boxes was completed and no changes to the policy were necessary.
4. All nursing supervisors will receive re-inservice education from the staff development coordinator or designee on the emergency box policy and procedure with emphasis on the monitoring for expired medications. The facility will develop and implement an audit tool to monitor compliance with the emergency box policy with regard to expired medications. The ADN or her designee will perform an audit weekly to ensure that there are no expired medications in any of the emergency boxes. Findings of the audit will be presented to the QAPI committee monthly for three months for evaluation. At the end of the three-month period the QAPI committee will determine the need of ongoing auditing or additional corrective actions.
5. The person responsible will be the NDS and the completion date will be 12/22/17.

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 25, 2017
Corrected date: December 22, 2017

Citation Details

Based on observation and staff interview conducted during the recertification survey, the facility did not ensure that all kitchen equipment was thoroughly cleaned and in good repair. Specifically, during the initial tour of the main kitchen area, several items, including the ansel system piping (chemical fire suppression equipment), ceiling light fixture, a ceiling tile in poor repair, exterior doors with an opening near the ground creating a portal of entry for insects and the exterior grounds were heavily littered and in need of thorough cleaning or repair work. The findings are: During the initial tour observation of the main kitchen area on 10/18/17 at 9:15 AM, the following was noted: 1) Three of the four ansel system piping that hung down directly over a cooking area were heavily soiled with dust and were in need of cleaning. 2) A ceiling lighting fixture in the dry goods storeroom was noted with debris and was in need of thorough cleaning. 3) A large ceiling tile in the dry goods storeroom measuring approximately 2 feet by 3 feet was noted to be in disrepair and in need of replacement. 4) The exterior doors used for food delivery to the main kitchen area had a gap along the bottom of the door creating a portal of entry for insects and was in need of repair. 5) The exterior grounds where food would be delivered was littered with cigarette butts, an empty cigarette package, dirty hampers and multiple dirty wheelchairs and was in need of thorough cleaning. The Director of Maintenance was interviewed on 10/18/17 at 10:30 AM and stated the person responsible to keep the grounds area neat and to clean the dirty equipment did not show up for work this morning. The Food Service Director was interviewed on 10/25/17 at 11:00 AM and stated the identified areas noted above were addressed by facility staff. 415.5(h)(2)

Plan of Correction: ApprovedNovember 17, 2017

1. No residents were affected by the deficient practice; all residents have the ptential to be affeced by the deficient practice.
2. The corrective actions were taken immediately following their identification as follows:
The ansul system piping was cleaned;
The ceiling light fixture was cleaned;
The ceiling tile was replaced;
A sweep/strip was placed at the bottom of the delivery-area doors to eliminate the gap;
The exterior grounds by the delivery area were thoroughly cleaned and equipment removed.
3. The Director of Environmental Services will create a cleaning schedule that includes more frequent inspection and cleaning of those areas identified;
the Director of Environmental Services will provide inservice to the housekeeping and maintenance staff on proper cleaning of the areas identified.
4. The Director of Environmental Services will make weekly rounds to complete an audit of the affected areas to ensure their cleanliness.
5. The Director of Environmental Services will report his findings monthly to the Administrator and to the QAPI Committee monthly for 3 months for evaluation and follow-up as necessary. At the end of the 3 month period, the QAPI Committee will determine the need for on-going monitoring or additional corrective action.
The Director of Environmental Services is responsible for the correction of this deficiency and the date of completion will be 12/22/2017

FF10 483.35(c); 483.95(g)(1)(2)(4):NURSE AIDE DEMONSTRATE COMPETENCY/CARE NEEDS

REGULATION: 483.35 (c) Proficiency of Nurse Aides The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents? needs, as identified through resident assessments, and described in the plan of care. 483.95 (g) Required in-service training for nurse aides. In-service training must- (g)(1) Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year. (g)(2) Include dementia management training and resident abuse prevention training. (g)(4) For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 25, 2017
Corrected date: December 22, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews during the recertification survey the facility did not ensure that a Certified Nursing Assistant (CNA#1) was able to demonstrate competency in skills and techniques necessary to care for residents needs. This was evident for 1 (Resident #57) of 1 resident reviewed for accidents in a total of 32 Stage two sampled residents reviewed. Specifically, Resident #57's CNA did not position the resident in her geri-chair correctly resulting in a skin tear. The finding is : Resident #57 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 3 indicating that the resident had severe cognition loss. The MDS documented the resident's transfer status as extensive assistance with two staff members. A Comprehensive Care Plan (CCP) dated 12/29/14 and titled 'Falls/Injuries' documented that on 10/13/17 the nurse went to the resident's room to assess a new skin impairment to the resident's left lateral calf. The CCP documented an open area was observed that measured 3 centimeters (cm) by 1.5 cm with scant blood and a purple discoloration around the circumference. The CCP documented interventions as follows: ensure that gentle handling of the resident is provided at all times, monitor healing, assess skin every shift. A physician progress notes [REDACTED]. An Accident and Incident (A/I) Report dated 10/13/17 documented that the RN assessed the resident's left calf after the CNA reported bleeding. The RN assessed that the resident had a skin tear to the left lateral calf and that the resident's calf was leaning against the corner of the geri-chair. The A/I documented that upon investigation the resident's geri-chair was evaluated and it was observed that the resident was not properly positioned in the center of the geri-chair after being transferred. The A/I also documented that the resident's CNA was educated on proper positioning of residents transferring to the geri-chair with the use of the mechanical lift. An inservice education procedure dated 5/2010 was presented by the previous RN educator to CNA#1 and CNA#2 on 8/22/17. The inservice education documented instructions on how to correctly operate the mechanical lift to ensure the safety of the residents and to reduce the prevalence of injuries. An interview was held with the CNA#1 on 10/24/17 at 9:30 AM. CNA#1 stated that she and CNA#2 transferred the resident out of bed to the geri-chair on 10/13/17. The CNA stated that she used a mechanical lift to transfer the resident and when she put the resident in the geri-chair the resident was not in the center of the chair. The CNA stated that the resident's left calf was too close to edge of the metal on the geri-chair and the metal cut the resident's left calf. The CNA stated that she was re-educated after the incident to ensure the resident is centered in the geri-chair during the mechanical lift transfer. An interview was held on 10/24/17 at 10:15 AM with the RN Supervisor. The RN stated that CNA#1 informed her that the resident's left calf was bleeding. The RN stated that she went to assess the resident and observed that the resident's left lateral calf was bleeding and had an open area. The RN stated that the resident's left lateral calf was hitting the side of the geri-chair, pressing against the plastic/metal area of the geri-chair. An interview was held with the RN Assistant Director of Nursing (ADNS) on 10/24/17 at 10:30 AM. The RN ADNS stated that she went to examine the chair and complete an investigation to determine the cause of the injury. The RN ADNS stated that it was determined that the arm had a metal area and that the resident's left calf was pressed against the metal part of the arm. The RN ADNS stated that it was determined that the injury was the result incorrect positioning in the geri-chair by the CNA. An observation of the resident's geri-chair was made on 10/24/17 at 11:00 AM. The observation revealed that at the end of the armrest there was metal with a sharp hard plastic piece surrounding the metal. An interview was held with the Director of Nursing Services (DNS) on 10/25/17 at 7:15 AM. The DNS stated that CNA#1 and CNA #2 should have known how to position the resident correctly in the geri-chair. An interview was held with CNA#2 who assisted CNA#1 (with the mechanical lift transfer) on 10/25/17 at 9:17 AM. The CNA stated that she did not notice that the resident was positioned incorrectly in the geri-chair after the mechanical lift transfer. 415.26(c)(1)(iv)

Plan of Correction: ApprovedNovember 21, 2017

1. Resident #57's wound was treated and healed. The CNAs identified in the incident have been re-inserviced with an emphasis on mechanical lift procedures.
2. Any patient that is transferred via mechanical lift are considered at risk. The policy and procedure for mechanical lift was reviewed and no changes were necessary.
3. All CNAs will be re-inserviced with an emphasis on appropriate use of mechanical lifts and the positioning of a patient in a geri-chair. All CNAs will have a mechanical lift competency completed.
4. The staff development coordinator or her designee will monitor two mechanical lifts per week for proficient practice and report to the QAPI committee monthly for three months for evaluation and follow up as indicated and necessary. At the end of the three month period the QAPI committee will determine the need of ongoing auditing or additional corrective actions.
5. The person responsible will be the DNS and the completion date will be 12/22/17.

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 25, 2017
Corrected date: December 22, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews conducted during a recertification survey, the facility did not ensure that the plan of care was followed for 1 (Resident # 57) of 1 resident reviewed for accidents from a total Stage 2 sample of 32 residents. Specifically, Resident # 57 developed a skin tear to the left calf during a mechanical lift transfer. The plan of care indicated to monitor the area every shift; however, there was no documented evidence that the skin tear was monitored every shift. The finding is: Resident #57 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated that the resident had severely impaired cognition. The nursing progress note of 10/13/17 documented that a Registered Nurse (RN) was called to the resident's room to assess a skin tear. The RN documented that the Certified Nursing Assistant (CNA) stated to her that the resident's leg was pushed against the metal of the chair. The resident sustained [REDACTED]. This incident was investigated by the facility. A Comprehensive Care Plan (CCP) initiated on 12/29/14 and titled 'Falls/Injuries' documented that on 10/13/17, the resident had an opened area measuring 3 cm. x 1.5 cm, with scant blood and a purple discoloration around the circumference. The goal of this CCP was that the resident will be free of infection. The interventions to achieve this goal included to ensure that gentle handling of the resident was provided at all times, monitor healing of the wound, and assess skin every shift. The physician progress notes [REDACTED]. The Physician's Progress Note documented to initiate a treatment with a topical ointment ([MEDICATION NAME]) and to apply clean, dry dressing two times a day until healed. The Treatment Administration Record dated 10/23/17 documented to cleanse the skin tear to the left lateral calf with normal saline solution, apply [MEDICATION NAME] ointment and cover with clean, dry dressing once a day. An observation of the resident's left lateral calf skin tear was conducted on 10/25/17 at 10:15 AM with the Licensed Practical Nurse (LPN #1) treatment nurse. The area around the skin tear was reddened and measures approximately 7 inches above and 8 inches below the skin tear. There was yellowish discharge noted on the bandage that was covering the skin tear. The LPN was interviewed at this time, and stated that the resident gets redness of her skin in other areas and the left calf was not reddened yesterday. Review of the resident's clinical record revealed no documentation describing the resident's skin condition between the date the skin tear was sustained on 10/13/17 and 10/25/17 to monitor the skin condition and possibly revise the treatment plan to prevent further deterioration and infection. The above CCP indicated to assess the resident's skin every shift. LPN #1 was interviewed on 10/25/17 at 10:16 AM and stated that the redness around the skin tear was not observed during a dressing change on 10/24/17 and there were no signs of infection. There was no documented evidence that the wound condition was documented in the resident's clinical record. The RN Wound Care Nurse (WCN) and the DNS were both interviewed on 10/25/17 at 11:00 AM. The WCN stated that she assessed the left lateral calf skin tear on 10/25/17 and it measured 4.5 cm. x 3 cm. x 0.2 cm. There was swelling around the wound, including the areas above and below the skin tear. The WCN stated that she notified the physician at that time and he ordered Keflex (an antibiotic) 500 mg via gastric tube three times a day for 10 days for the redness of the resident's calf skin tear and ordered [MEDICATION NAME] ointment two times a day. The WCN stated further that she assessed the skin tear on the left lateral calf on 10/20/17. There was no evidence of the WCN's assessment of the skin condition on 10/20/17. The DNS was interviewed at this time and stated that she spoke with the LPN who applied the treatment on 10/24/17 and stated that the areas looked fine. (According to the New York State Licensed Practical Nurse Scope of Practice, 6901 of Article 139 of the Education Law, LPNs do not have assessment privileges; they may not interpret patient clinical data or act independently on such data.) The resident's CNA was interviewed on 10/24/17 at 9:30 AM stated she and another CNA transferred the resident out of her bed to the geri-chair on 10/13/17. The CNA stated that she used a mechanical lift transfer and when she put the resident in the geri-chair the resident was not in the center of the chair and that the resident's left leg was to close to edge of the metal on the chair and cut the resident's left leg. The CNA stated that she was re-educated after the incident to ensure the resident is centered in the geri-chair during the mechanical lift transfer. The CNA also stated she checks the resident's skin every day but not the injured area , the nurses do that. The RN Assistant Director of Nursing (ADNS) was interviewed on 10/24/17 at 10:30 AM and stated she went to examine the chair and complete an investigation to determine the cause of the injury. The RN ADNS stated the geri-chair was reclined back when the incident happened and it was determined that the arm had a metal area and that the residents left calf was pressed against the metal part of the arm. The RN ADNS stated that it was determined that the injury was the result incorrect positioning in the middle of the geri-chair by the CNA. The Physician was interviewed on 10/25/17 at 11:45 AM and stated he was aware that the resident received the laceration of the left lateral calf skin tear from the resident's geri-chair.The Physician stated he did not document an assessment of the left lateral calf skin tear. The 3:00 PM -11:00 PM shift LPN #2 was interviewed on 10/25/17 at 11:55 AM. LPN #2 stated that the resident's treatment is done once a day. The Physician was further interviewed on 10/26/17 at 2:30 PM and stated that he received a call from the nurse today and the nurse stated that the skin tear area was getting worse and it was red. The Physician stated that he came to the facility to do an assessment of the laceration on 10/26/17 today and determined that it measured 4.5 cm by 3 cm by 0.2 cm depth (which is a deterioration from the initial size of 3 cm by 1.5 cm with no depth). The Physician also stated the skin below and above the knee was a local reaction to the laceration and to continue the Keflex. The Physician also stated that maybe the laceration is getting an infection underneath the skin and we are treating it with an antibiotic. The Physician stated that signs of infection include redness and inflammation. 415.11(c)(3)(ii)

Plan of Correction: ApprovedNovember 21, 2017

1. Resident #57 was not affected by the deficient practice. Resident #57's wound had already healed and the care plan had been resolved as of 11/3/17.
2. All patient's care plans for wound care will be reviewed for appropriate interventions with emphasis upon the qualified person being able to provide the services described within the interventions. Any interventions that cannot be carried out appropriately will be revised.
3. All Registered Nurses will be re-inserviced with regard to developing a care plan with emphasis on ensuring that interventions are written so that a qualified person is able to carry out the intervention. All wound care interventions that require the monitoring of a licensed nurse will be transcribed on the MAR indicated [REDACTED].
4. An audit tool will be developed to monitor interventions to ensure that qualified persons will carry out the interventions as written in the patient's plan of care an documented accordingly. The ADN or her designee will monitor 10% of all new wound care plans weekly for interventions that are written to allow for qualified persons to carry out the services that are described in those interventions and that those interventions are documented appropriately on the MAR, TAR and or CNAAR and report to the QAPI committee monthly for three months. At the end of three months the QAPI committee will determine the need for ongoing auditing or additional corrective actions.
5. The person responsible will be the DNS and the date of completion will be 12/22/17.

Standard Life Safety Code Citations

K307 NFPA 101:BUILDING CONSTRUCTION TYPE AND HEIGHT

REGULATION: Building Construction Type and Height 2012 EXISTING Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7 19.1.6.4, 19.1.6.5 Construction Type 1 I (442), I (332), II (222) Any number of stories non-sprinklered and sprinklered 2 II (111) One story non-sprinklered Maximum 3 stories sprinklered 3 II (000) Not allowed non-sprinklered 4 III (211) Maximum 2 stories sprinklered 5 IV (2HH) 6 V (111) 7 III (200) Not allowed non-sprinklered 8 V (000) Maximum 1 story sprinklered Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: October 25, 2017
Corrected date: December 22, 2017

Citation Details

The following requirement of the Life Safety Code has been previously waived. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews, and certification that the conditions under which the waivers have been granted have not changed. Please indicate if the facility wishes the waiver to be continued, or provide a plan of correction. K161, S/S=B The facility is a 3 story, Type II (000) construction building that is fully sprinkered. The Life Safety Code prohibits Type II (000) buildings from being more than two stories in height with complete automatic sprinkler system. 483.70 (a), NFPA [PHONE NUMBER]: 19.1.6.2, 10NYCRR: 711.2(a)(1) NYCRR 711.2(a)(1)

Plan of Correction: ApprovedNovember 10, 2017

The facility has requested a continance of this waiver.

K307 NFPA 101:DISCHARGE FROM EXITS

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 25, 2017
Corrected date: December 22, 2017

Citation Details

2012 NFPA 101: 19.2.7 Discharge from Exits. Discharge from exits shall be arranged in accordance with Section 7.7. 2012 NFPA 101: 7.7.3.2 The exit discharge shall be arranged and marked to make clear the direction of egress travel from the exit discharge to a public way. Based on observation and staff interview, the facility did not ensure that exit discharge is arranged in accordance with NFPA 101: 7.7 in that exit signage was not provided at exit discharge locations to direct egress travel to a public way. This was noted for exits from the 1st floor. The findings are: On 10/24/17 between 9:00am- 1:00pm during the recertification survey, exit signage was observed lacking at exit discharge locations from the 1st floor to direct egress travel to a public way. Examples are: 1) The Stairs that discharge in the vicinity of the smoking gazebo 2) Main dining room 3) Rehabilitation gym 4) Exit discharge from the service area. On 10/18/17 at approximately 9:30am, a dish machine was observed in a path adjacent to the emergency exit. There was no signage to direct egress away from this path and towards the public way. In an interview on 10/24/17 at approximately 10:30am, the facility's consultant stated that they would put up the exit signs. 2012 NFPA 101: 19.2.7, 7.7.3.2 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedNovember 10, 2017

K271

A. No residents were affected by the deficient practice.
B. All residents have the potential to be affected by the deficient practice.
C. 1. The Director of Maintenance purchased and installed directional egress signage to properly direct egress travel to the public way from discharge locations conforming with NFPA standards.
2. The Director of Maintenance will conduct a quarterly audit to ensure all egress signage meet NFPA standards.
D. 1. The Director of Maintenance/designee will report finding of audit to administrator.
2. Administrator will report findings of this audit at the next quarterly QA meeting.
E. The Director of Maintenance is responsible for the correction of this deficiency.

K307 NFPA 101:SPRINKLER SYSTEM - SUPERVISORY SIGNALS

REGULATION: Sprinkler System - Supervisory Signals Automatic sprinkler system supervisory attachments are installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and provide a signal that sounds and is displayed at a continuously attended location or approved remote facility when sprinkler operation is impaired. 9.7.2.1, NFPA 72

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: October 25, 2017
Corrected date: December 22, 2017

Citation Details

The following requirement of the Life Safety Code has been previously waived. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews, and certification that the conditions under which the waivers have been granted have not changed. Please indicate if the facility wishes the waiver to be continued, or provide a plan of correction. K352, S/S=B The sprinkler system RPZ/water backflow prevention control valve located in an exterior vault enclosure is not provided with an electronic supervisory device. NFPA [PHONE NUMBER] Life Safety Code: 9.7.1.2, NFPA 13, NFPA 72, 10NYCRR, 415.29 (a) (2)

Plan of Correction: ApprovedNovember 10, 2017

The facility has requested a continance of this waiver

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: Pattern
Severity: Potential to cause minimal harm
Citation date: October 25, 2017
Corrected date: December 22, 2017

Citation Details

The following requirement of the Life Safety Code has been previously waived. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews, and certification that the conditions under which the waivers have been granted have not changed. Please indicate if the facility wishes the waiver to be continued, or provide a plan of correction. K311, S/S=B Vertical duct penetrations which passed through the floor/ceiling assembly of the building were not enclosed in at least 1-hour fire resistance rated construction. 483.70(a), 711.2(a)(1), 2012 NFPA 101: 19-3.1.1, 19-5.2.1, NFPA 90A

Plan of Correction: ApprovedNovember 10, 2017

The facility has requested a continance of this waiver