Oneida Health Rehabilitation and Extended Care
February 27, 2018 Certification/complaint Survey

Standard Health Citations

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: February 27, 2018
Corrected date: March 15, 2018

Citation Details

Based on observation and interview conducted during the recertification survey, the facility did not ensure 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 1 of 10 employees reviewed for influenza (flu) vaccinations. Specifically, one employee did not receive the flu vaccine and was observed not wearing a mask correctly during the designated flu season. Findings include: Review of employee health records revealed registered nurse (RN) Supervisor #4 declined an influenza vaccine on 10/7/2017. Review of a New York State (NYS) Department of Health (DOH) Health Advisory dated 12/13/2017 revealed the NYS DOH Health Commissioner declared influenza to be prevalent in NYS for the (YEAR)-18 influenza season. The Health Advisory documented that all healthcare facilities shall ensure that all personnel not vaccinated against influenza for the current influenza season wear a surgical or procedure mask while in areas where residents are typically present. The Advisory directed facilities to activate their policy and procedure to ensure compliance with Section 2.59 of the NYS Sanitary Code. The following observations were made: - On 2/22/2018 at 12:09 PM, registered nurse (RN) Supervisor #4 was in a resident care area gathering residents for lunch with her flu mask off of her face. - On 2/22/2018 at 12:17 PM, RN Supervisor #4 was serving trays in the dining room with her flu mask down beneath her face. - On 2/22/2018 at 12:27 PM, RN Supervisor #4 was on the phone, in the hall, and in the dining room feeding an unidentified resident with her flu mask beneath her face. - On 2/22/2018 at 2:30 PM, RN Supervisor #4 was wearing her flu mask beneath her nose in a resident care area. When interviewed on 2/27/2018 at 11:10 AM, RN Supervisor #4 stated she had training regarding the use of the flu mask. It should be pinched above the nose and secured behind the ears so it was covering the mouth and nose and beneath the chin. It should be in place while around residents to protect the residents and herself. She stated she pulled the mask down when she used the stairs and forgot to pull it back up. The infection control nurse #5 was interviewed on 2/27/2018 at 2:25 PM and she stated she kept a running log of the flu vaccination status of all employees. Department heads and nurse managers were updated with names of employees who declined the flu vaccination and needed to be wearing masks. When an employee signed a flu vaccination declination, instruction on how to don a mask was provided and the employee must return demonstrate donning of the mask. 10NYCRR 415.19(a)(1-3)

Plan of Correction: ApprovedMarch 15, 2018

F880-In the recent standard recertification survey it was determined the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure 1 unvaccinated employee wore flu mask properly to prevent the spread of infection as they did not receive the annual influenza vaccine.
The following steps were taken:
1) Supervisor #4 was educated on the proper use placement, application of the masks and returned demonstration of proper use of mask on 3/15/2108.
Date completed: 3/15/18
2) All unvaccinated employees have demonstrated that they are using their masks in accordance with policy. In addition, all unvaccinated staff were re-educated on the importance of continued proper use and placement/application of masks.
Date completed: 3/12/18

3) The facility infection control policy for declination of influenza and the use of masks was reviewed and includes the proper placement/application of masks.
Date completed: 3/9/18
4) All facility staff will be educated on the review of the infection control declination of influenza and use and placement/application of masks. The code of conduct for residents and co-workers will reviewed with all staff to reinforce that it is each person?s responsibility to protect residents and co-workers from spread of infection.
Date completed: 3/21/18
5) Infection control/designee will conduct audits every shift to ensure all unvaccinated employees are wearing masks and are properly in place.
Date completed: Ongoing until end of Flu Season.
6) QA committee will evaluate the frequency of the audit and define if necessary.
Date completed Ongoing
Owner: Infection Control Manager

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: Potential to cause more than minimal harm
Citation date: February 27, 2018
Corrected date: April 1, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification survey, the facility did not ensure 3 of 10 residents (Residents #45, 106, and 493) reviewed for advance directives had the right to formulate advance directives. Specifically, Resident #106 and #493's Medical Orders for Life Sustaining Treatment (MOLST) were completed by their health care proxies (HCP, a person designated to make health care decisions for someone determined to lack capacity for decision making) and there was no documentation the physician determined the resident's lack of capacity at the time of the MOLST completion. Resident #45's MOLST was incomplete. Findings include: The facility's Advance Directives: Advance Care Planning for Healthcare Decisions policy revised 12/2016 documented the following: - The MOLST will be completed upon admission and the physician determines the resident's capacity to make medical decisions and obtains concurring determination of lack of capacity. - The physician will review and renew the advance directives on admission, readmission, and every 60 days thereafter. - Advance directives can be revised at any time at the request of the resident or HCP and if changes are made, a new MOLST must be completed and the old MOLST voided. - Determination of lack of capacity for patients who have a health care proxy must be made by two physicians and must be in writing in the medical record describing the course, nature, extent, and probable duration of the incapacity. 1) Resident #45 was admitted [DATE] and had [DIAGNOSES REDACTED]. The 1/30/2018 Minimum Data Set (MDS) assessment documented the resident had intact cognition and required extensive assistance for most of her activities of daily living (ADLs). The comprehensive care plan (CCP) updated 2/6/2018 documented the resident had a HCP and effective 1/23/2018, the resident became DNR (Do Not Resuscitate) status and the MOLST was updated. The physician orders [REDACTED]. The MOLST form was signed by the physician on 1/23/2018. In one area it was documented the resident made the decision regarding DNR status and the form was not signed by the resident. There was no check mark and date on the form indicating the resident gave verbal consent for the DNR. Social worker #2 was interviewed on 2/27/2018 at 11:50 AM and stated she would consider an incomplete MOLST invalid and a new form would be completed. The Medical Director was interviewed on 2/27/2018 at 3:10 PM and stated correct completion of a MOLST form included education for those involved and he was working on that. The physician reviewed the MOLST and stated the MOLST was incomplete and not signed by the resident. 2) Resident #493 was admitted [DATE] and had a [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated 2/16/2018 documented the resident had dementia. Interventions included explaining changes in care, medications, and treatment. There was no advance directive care plan in place. The physician orders [REDACTED]. The MOLST form was signed by the physician and healthcare proxy (HCP) on 2/9/2018. There was no documentation the physician determined the resident's lack of decision making capacity at the time of the MOLST completion. Social worker #2 was interviewed on 2/27/2018 at 11:50 AM and stated normally the physician addressed advance directives when the history and physical was completed. If a resident was unable to make decisions and had a HCP, the physician should fill out a lack of capacity form which required two physicians' signatures. If the resident was alert and oriented, it was not necessary for the HCP to sign the MOLST. The physician may feel the resident was able to make medical decisions even if they had a cognitive impairment. Registered nurse (RN), unit manager #1 was interviewed on 2/27/2018 at 11:55 AM and stated she had not been involved in completing a two-physician lack of capacity form since she had been working at the facility and was unfamiliar with its completion. Physician #3 was interviewed on 2/27/2018 at 2:00 PM and she stated completing a lack of capacity form depended on the circumstances and it may involve the social worker or a psychiatrist. If a resident had a [DIAGNOSES REDACTED]. The Medical Director was interviewed on 2/27/2018 at 3:10 PM and stated a two-physician lack of capacity form should be completed with the MOLST if a resident had a HCP who was going to be involved in decision-making. 3) Resident #106 was readmitted [DATE] and had a [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated 2/12/2018 documented the resident had a HCP and was DNR status and her wishes would be honored. The physician orders [REDACTED]. The MOLST form dated 1/19/2018 documented the previous form was voided and a new form was completed and signed by the physician and HCP. There was no documentation the physician determined the resident lacked capacity at the time of the new form completion on 1/19/2018. Social worker #2 was interviewed on 2/27/2018 at 11:50 AM and she stated she was not sure why the HCP signed the MOLST as the resident had a BIMS (Brief Interview for Mental Status, test for cognition) of 14 out of 15 (intact cognition) and the resident should have been able to make her own decision. 10NYCRR 415.3(e)(1)(ii)

Plan of Correction: ApprovedApril 4, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F578 The facility did not ensure that 3 out of 10 (45, 106, and 493) residents reviewed for advanced Directives had the right to formulate advance directives.
1)Correction: Resident #45- MOLST was signed by physician on 1/23/2018; however, the resident did not sign the form. In one area it was documented that resident made the decision regarding DNR status; however, the form was not signed by the resident and there was no check mark and date that resident gave consent for DNR. Resident signed new MOLST form dated 2/27/2018. Date and time were completed on the new MOLST Form.
Resident #493 had a [DIAGNOSES REDACTED]. There was no advanced directive care plan in place. Advanced Directive Care Plan was completed on 2/23/ (YEAR). The MOLST form was signed by physician and HCP- there was no documentation that physician determined lack of capacity for decision making at the time of the MOLST completion. Physician determined on 2/27/2018 that resident was able to make her own health care decisions and a new MOLST form was completed and signed and dated by resident.
Resident #106 MDS assessment documented that resident had intact cognition. The MOLST Form dated 1/19/2018 documented the previous form was voided and a new form was completed and signed by the physician and HCP. There was no documentation, the physician determined the resident lacked capacity at the time of new form completion. Resident #106 had a DNR status at the time incapacity was determined per NP progress note dated 1/10/17. An Incapacity Form was completed on 1/11/17 by physician with concurring physician signature signed on 11/15/17 to determine that Resident #106 did not have capacity due to a [DIAGNOSES REDACTED]. On NP progress note dated 2/15/2018, resident was reassessed for lack of capacity for decision making and it was determined that resident remains unable to make her own health care decisions due to her [DIAGNOSES REDACTED].
2) How Facility will protect Residents
a. Social Services to continue an ongoing audit of MOLST and Lack of Capacity for Decision Making Forms after completion of the forms for all new admissions. (Ongoing)
b. A Sample Audit of 10 residents per floor will be completed by 3/16/2018 to identify any MOLST Forms that require correction and update accordingly by 3/23/17.
c. A full house audit on Lack of Capacity Forms will be completed by 4/1/2018
d. A full house audit on MOLST Forms will be completed by 4/1/2018
3) Measures the Facility will take to ensure Problem does not recur:
a. To ensure the facility does not have this problem recur ?OHC will:
i. Provide Physician; Nursing staff education on how to correctly complete MOLST Forms by Social Services or designee on or before 4/1/2018.
ii. MOLST Forms will continue to be completed within a 48 hour period upon admission and readmission. (Ongoing).
1. MOLST Forms from other facilities will continue to be audited for completion at the time of admission (Ongoing).
a. If MOLST Form from other facility is incorrect ? a new MOLST Form to be completed at time of admission and readmissions. (Ongoing)
iii. Will continue to complete Lack of Capacity For Decision Making Form at the time of MOLST Form and with Change of Condition, if needed. (Ongoing).
iv. MOLST Forms will continue to be completed by Physician and/or RN (ongoing).
v. Lack of Capacity Forms to be completed by Physician with a concurring signature along with MOLST Form. (Ongoing).
1. In order to determine capacity the Physicians will visit with resident, review chart and evaluate as needed: physical and neurological exams as well as establish level of cognition in order to determine capacity.
vi. Social Services to continue an ongoing audit of MOLST and Lack of Capacity for Decision Making Forms after completion of the forms for all new admissions and readmissions and with Change of Condition. (Ongoing)
vii. Physicians to Complete Section F: Review and Renewal for MOLST Forms every 60 days to maintain validity and compliance of forms (Ongoing)
4) How the facility will ensure the solution is sustained: Social Services to continue to complete facility wide monthly audits on MOLST and Lack of Capacity For Decision Making Forms to ensure that the solution to forms is sustained. (Ongoing).
Owner: Director Of SW or designee

Standard Life Safety Code Citations

K307 NFPA 101:FIRE ALARM SYSTEM - TESTING AND MAINTENANCE

REGULATION: Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2018
Corrected date: March 15, 2018

Citation Details

Based on record review and interview conducted during the recertification survey, the facility's fire alarm system was not tested in accordance with the requirements of NFPA 72. Specifically, the semi-annual test for the second half of (YEAR) was not completed. Findings include: During review on 2/26/2018 of the annual fire alarm inspection reports provided by the facility, a surveyor observed the inspection reports were completed on 6/10/2016 and 6/12/2017. There was no documented fire alarm inspection reports for the end of (YEAR)/beginning of (YEAR) and end of (YEAR)/beginning of (YEAR). During an interview on 2/27/18 at 10:09 AM, the Plant Operations Director stated the semi-annual fire alarm system visual inspections were completed during the course of the year, but not documented. 2012 NFPA 101: 19.3.4.1, 9.6.1.3 2010 NFPA 72: 14.1 10 NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedMarch 15, 2018

K345 Fire Alarm System- The Facility?s Fire Alarm Systems was not tested in accordance with the
requirement of NFPA 72. The system was fully tested annually and missed the documentation of the other 6 month visual inspection.
It had yet to be tested for the end of (YEAR)>2017, end of (YEAR)>2018. It was reported that they occurred but were not documented.
1) Correction-As such, we will have instituted a documented Semi-annual Visual/Full Fire Alarm system test commencing with the visual on (MONTH) 19, (YEAR), with the second full testing slated for (MONTH) (YEAR). The visual test will be completed by Oneida Healthcare staff and the annual full testing by our contractor ABJ Fire Systems. Oneida staff will also complete another visual in (MONTH) of (YEAR) to put us on schedule for the semi annuals every 6 months to include the visuals and full testing requirements.
2) Recurrence will be prevented through having this requirement as a scheduled Semi-annual event in our Four(NAME)PM Maintenance software. Documentation of these events will be recorded in our test reports from ABJ and our maintenance team reports. All documentation will be kept in our ECF Life Safety Files report manual.
Formal staff education on process changes and expectations will be conducted during the (MONTH) 22, (YEAR) scheduled staff meeting. We did hold an informal meeting with the facilities staff and our contractor to put plans in effect to address this issue as well on (MONTH) 28, (YEAR).
3) As a measure of compliance- the Semi-annual testing reports will be shared and detailed at the combined ECF/ACF Safety Committee Meeting where the results can be reviewed and discussed. The report will be presented at the first Safety Committee meeting following the events completion. As proof of completion, copies of the semiannual event will be provided to the ECF Administrator for inclusion in QAPI Reporting. (Administrator is also a member of the Safety Committee).
Owner: Administrator and Director of plant Operations

K307 NFPA 101:FUNDAMENTALS - BUILDING SYSTEM CATEGORIES

REGULATION: Fundamentals - Building System Categories Building systems are designed to meet Category 1 through 4 requirements as detailed in NFPA 99. Categories are determined by a formal and documented risk assessment procedure performed by qualified personnel. Chapter 4 (NFPA 99)

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2018
Corrected date: March 15, 2018

Citation Details

Based on interview conducted during the recertification survey, the facility did not ensure a formal and documented risk assessment procedure for the building system categories was performed. Specifically, the buildings system categories assessment was not completed. Findings include: During an interview on 2/27/2018 at 1:36 PM, the Plant Operations Director stated a formal and documented risk assessment procedure for the building system categories had not been completed for the facility. He was not aware of this requirement. 2012 NFPA 99 - Chapter 4 10 NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedMarch 15, 2018

K 901 Fundamentals Building System Categories- the facility did not insure a formal and documented risk Extinguisher procedure for the building system categories was performed. The building system categories assessment was not completed.
1) Correction-As such, we will have conducted a Multi-Disciplinary Building Systems Risk Assessment which details, ranks and categorizes the Building Systems vulnerabilities and identifies areas that require further focus or intervention was conducted on 3/14/18. We have incorporated the Equipment into the Facility Assessment Manual and an online workgroup. Emergency Management has its own longstanding separate manual. Areas and items at risk were identified and will be acted upon accordingly. This will be incorporated into the Facility Risk Assessment Manual and be reviewed and updated annually by a cooperative effort of the Administrator and the Plant Operations Director
2) Recurrence will be prevented through inclusion in the Facility Risk Assessment Manual which will be reviewed Annually in (MONTH) and draw members from the ECF Staff and/or Safety Committee Members as part of the SWOT component of the Assessment.
Staff education on process changes and expectations was conducted on 3/14/18.
3) As a measure of compliance- the Building System Risk Assessment results/findings will be shared and detailed at the combined ECF/ACF Safety Committee Meeting where the results can be further reviewed and discussed on 3/20/18. The report will be presented at the first Safety Committee meeting following the events completion 3/20/18. As proof of completion, copies of the semiannual event will be provided to the ECF Administrator. (Administrator is also a member of the Safety Committee).
Owner: Administration and Director Of Plant Operations

K307 NFPA 101:PORTABLE FIRE EXTINGUISHERS

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2018
Corrected date: March 15, 2018

Citation Details

Based on observation, record review, and interview conducted during the recertification survey, the facility's portable fire extinguisher for 1 isolated room (boiler room) was not maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. Specifically, the only fire extinguisher in the boiler room had a pressure gauge not in the operable range. Findings Include: On 2/26/2018 at 2:14 PM, a surveyor observed the only fire extinguisher in the boiler room had a pressure gauge not in operable range, as the needle was in the recharge zone of the dial. The paper tag on the fire extinguisher indicated the last monthly visual check was done on 2/23/2018. During review on 2/26/2018 of the (YEAR) monthly fire extinguisher inspection sheet, a surveyor observed that the boiler room fire extinguisher was completed for (MONTH) (YEAR), with no comments noted. The inspection form indicated Pressure Gauges In Operable Range was one of the items visually checked on a monthly basis. During an interview on 2/26/2018 at 2:14 PM, the Maintenance Supervisor stated he was unaware that the boiler room fire extinguisher was not fully charged. The night maintenance staff was responsible for doing the monthly fire extinguisher checks. 2012 NFPA 101: 19.3.5.12, 9.7.4.1 2010 NFPA 10 10 NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedMarch 15, 2018

K355 Portable Fire Extinguishers- A surveyor observed that the only fire extinguisher in the Boiler Room had a pressure gauge not in operable range as the needle was in the recharge zone. On the dial, the paper tag on the fire extinguisher indicated the last monthly visual check was done on 2/23/2018. On review of the (YEAR) monthly fire extinguisher incident inspection sheet a surveyor observe that the Boiler Room fire extinguisher was completed for (MONTH) (YEAR) with no comments noted. The inspection form indicated the pressure gauges in operable range.
1. Correction: A full building assessment of extinguishers was conducted on (MONTH) 13, (YEAR) to identify any other non-compliant extinguishers. All corrections have been made. Boiler room extinguisher was replaced on (MONTH) 26, (YEAR). During the environmental rounds the extinguishers in the area inspected will also be checked by the rounding inspectors and documented on the E(NAME) sheet. Any failed units will be replaced
on a rush basis.
2. Recurrence will be prevented through having a detailed PM Maintenance of the extinguishers, which will include checking the following components of the extinguishers: Verify location, visible and not obstructed, instructions are legible, seal/tamper indicators are intact, check fullness, examine for corrosion, damage, dents, gauge indicator in normal position. The routine PM Maintenance program to include these components was updated on (MONTH) 2, (YEAR). Routine Extinguisher Testing to include a full check of operating components is scheduled to commence in (MONTH) of (YEAR). Documentation of the inspection will be recorded in the Four(NAME)Maintenance CMMS system and kept in our ECF Life Safety manual.
3. Formal staff education on process changes and expectations will be conducted during the (MONTH) 22, (YEAR) scheduled staff meeting. We did hold an informal meeting with the facilities staff to put plans in effect to address this issue as well on (MONTH) 28, (YEAR)
4. As a measure of compliance- the Extinguisher Testing Reports will be shared and detailed at the combined ECF/ACF Safety Committee Meeting where the results can be reviewed and discussed. The report will be presented at the first Safety Committee meeting following the events completion. As proof of completion, copies of the Extinguisher Testing will be provided to the ECF Administrator for inclusion in QAPI Reporting (Administrator is also a member of the Safety Committee).
Owner Administrator and 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: February 27, 2018
Corrected date: March 15, 2018

Citation Details

Based on observation and interview conducted during the recertification survey, the facility did not ensure the building was protected throughout by an approved automatic sprinkler system for 3 of 3 emergency exit stairwells (east stairwell, north stairwell, west stairwell), and 2 isolated areas (fourth floor tub room, basement loading dock), in accordance with National Fire Protection Association (NFPA) 13 - Standard for Installation of Sprinkler Systems section 8.3.3.2. Section 8.3.3.2 states: Where quick response sprinklers are installed, all sprinklers within a compartment shall be quick response unless otherwise permitted in 8.3.3.3. Specifically, east emergency exit stairwell, the north emergency exit stairwell, the west emergency exit stairwell and the basement loading dock contained both quick response sprinkler heads and standard response sprinkler heads; and the fourth floor tub room had a damaged sprinkler head. Findings include: 1. Mixed Sprinkler Heads On 02/26/2018 at 11:04 AM, a surveyor in the east emergency exit stairwell observed floors five through one contained 5 quick response heads and 2 standard response sprinkler heads. Floors 1 through the basement contained 2 quick response heads and 2 standard response heads. On 02/26/2018 at 1:50 PM, a surveyor in the north emergency exit stairwell observed 4 quick response heads and 2 standard response sprinkler heads. On 02/26/2018 at 1:50 PM, a surveyor in the west emergency exit stairwell observed 2 quick response heads and 6 standard response sprinkler heads. On 02/26/2018 at 2:10 PM, a surveyor in the basement loading dock observed 1 quick response head and 4 standard response sprinkler heads. During an interview on 2/27/2018 at 10:17 AM, the Plant Operations Director stated he did not know the emergency exit stairwells and the basement loading dock contained mixed sprinkler heads. He though they were all quick response sprinkler heads and was was unaware of this regulation. 2. Damaged Sprinkler Head On 02/26/2018 at 1:46 PM, a surveyor in the fourth floor tub room observed a damaged sprinkler head with a bent deflector. During an interview on 2/26/2018 at 01:46 PM, the Plant Operations Director stated he was not aware of the damaged sprinkler head in the fourth floor tub room. 2012 NFPA 101: 19.3.5.1, 9.7.1.1 2010 NFPA 13: 8.3.3.2 10 NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedMarch 15, 2018

K351 Sprinkler System Installation/Mixed heads
The facility did not insure the building was protected by an approved automatic sprinkler system for 3 of 3 emergency exit stairwells east stairwell North stairwell with stairwell into isolated areas 4th floor tub room in basement loading dock.
? East emergency exit stairwell floors 1 through 5 contain 5 quick response heads and two standard response sprinkler heads. Floor one for the basement contain two quick response heads and two standard response heads.
? North emergency exit stairwell contained 4 quick response heads and 2 standard response sprinkler heads.
? West stairwell contained two quick response heads and 6 standard response sprinkler heads. The basement loading dock observed one quick response head and 4 standard response sprinkler heads.
? In the 4th floor tub room there was one damaged sprinkler head with a bent deflector.
1) Correction- A full building assessment of sprinklers was conducted on (MONTH) 28, (YEAR) to identify any other non-compliant sprinklers. ABJ Fire Protection Co. toured the facility and a bid was received 3/5/18 for corrections to the noncompliance. Replacement of mixed/damaged/non-compliant heads in locations as identified began on (MONTH) 9, (YEAR) and will be completed by 3/13/18.
2) Recurrence will be prevented through having a detailed PM Maintenance check of the Sprinkler heads, which will include age and condition checks as part of our scheduled routine PM Maintenance program. Routine Sprinkler Head visual Testing is scheduled to commence on (MONTH) 19, (YEAR). Documentation of these visuals will be recorded in the Four(NAME)Maintenance CMMS system and kept in our ECF Life Safety manual.
Formal staff education on process changes and expectations will be conducted during the (MONTH) 22, (YEAR) scheduled staff meeting. We did hold an informal meeting with the facilities staff and our contractor to put plans in effect to address this issue as well on (MONTH) 28, (YEAR)
3) As a measure of compliance- the Sprinkler Testing Reports will be shared and detailed at the combined ECF/ACF Safety Committee Meeting where the results can be reviewed and discussed. The report will be presented at the first Safety Committee meeting following the events completion. As proof of completion, copies of the Sprinkler Head Testing will be provided to the ECF Administrator for inclusion in QAPI Reporting. (Administrator is also a member of the Safety Committee).
Owners Admissions and Director 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: Widespread
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2018
Corrected date: March 15, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview conducted during the recertification survey, the facility did not ensure the building's automatic sprinkler system was tested in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems, for 6 of 6 floors (basement, first floor, second floor, third floor, fourth floor, and fifth floor). Specifically, the 20-year test was not completed for the quick response sprinkler heads located within the facility. Findings include: On 2/27/2018 at 4:00 PM, a surveyor observed: - the first floor conference room had 4 quick response sprinkler heads that were dated 1991; - the first floor lobby area contained 7 quick response sprinkler heads dated 1991; and - the first floor administration office had 1 quick response sprinkler head dated 1990, and two dated 1991. During an interview on 2/27/2018 at 4:11 PM, the Plant Operations Director stated all sprinkler heads in the facility were installed at the same time when the building was constructed in approximately 1992. He could not verify that a [AGE] year quick response sprinkler head test was completed, and that the third party vendor had no documentation. During review on 2/27/2018 of hand-written sprinkler heads total documentation for each floor provided by the Plant Operations Director, a surveyor observed there were 829 quick response sprinkler heads in the facility. The Plant Operations Director later corrected the count and indicated there were 826 total heads. 2012 NFPA 101: 19.3.5.1 2011 NFPA 25 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedMarch 15, 2018

K353 Sprinkler System Maintenance and testing- For 6 of 6 floors: basement, first floor, second floor, 3rd floor, 4th floor, and fifth floor the 20-year test was not completed for the quick response sprinkler heads located within the facility.
Findings include the first floor conference room had 4 quick response sprinkler heads that were dated 1991 the first floor lobby area contains 7 quick response sprinkler heads dated 1991 and the first floor Administration office had one quick response sprinkler head dated 1990 and two dated 1991 all sprinkler heads in the facility were installed at the same time when the building was constructed in approximately 1992 the facility could not verify that a 20-year Quick Response Sprinkler Head Test was completed. There is a total of 826 heads in the building.
1. Correction: A full building assessment of sprinklers was conducted on (MONTH) 28, (YEAR) to identify any other non-compliant sprinklers. Abj Fire Protection Co. bid received 3/5/18 for work completion. Nine heads were removed and replaced and sent out for 20-year test. Will receive results in 3-4 weeks and proceed as directed. Replacement of mixed/damaged/non-compliant heads in locations as identified has begun, will be completed by 3/13/18.
2. Recurrence will be prevented through having a detailed PM Visual Maintenance check of the Sprinkler heads, which will include age and condition checks as part of our scheduled routine PM Maintenance program. Routine Sprinkler Head Testing is scheduled to commence on (MONTH) 19, (YEAR). Documentation of these visuals will be recorded in the Four(NAME)Maintenance CMMS system and kept in our ECF Life Safety manual.
3. Formal staff education on process changes and expectations will be conducted on during the (MONTH) 22, (YEAR) scheduled staff meeting. We did hold an informal meeting with the facilities staff and our contractor to put plans in effect to address this issue as well on (MONTH) 28, (YEAR)
4. As a measure of compliance- the Sprinkler Visual/Testing Reports will be shared and detailed at the combined ECF/ACF Safety Committee Meeting where the results can be reviewed and discussed. The report will be presented at the first Safety Committee meeting following the events completion. As proof of completion, copies of the Sprinkler Head Visual Testing will be provided to the ECF Administrator for inclusion in QAPI Reporting. (Administrator is also a member of the Safety Committee).
Owners: Administrator and Director of Plant Operations