Elderwood at Waverly
January 17, 2019 Certification/complaint Survey

Standard Health Citations

E3BP 402.7(a)(2)(i):DEPARTMENT CRIMINAL HISTORY REVIEW

REGULATION: Section 402.7 Department Criminal History Review. (a) After reviewing a criminal history record of an individual who is subject to a criminal history record check pursuant to this Part, the Department and the provider shall take the following actions: ...... (2) Where the criminal history information of a prospective employee reveals a felony conviction at any time for a sex offense, a felony conviction within the past ten years involving violence, or a conviction for endangering the welfare of an incompetent or physically disabled person pursuant to section 260.25 of the Penal Law, or where the criminal history information concerning such prospective employee reveals a conviction at anytime of any class A felony, a conviction within the past ten years of any class B or C felony, any class D or E felony defined in articles 120, 130, 155, 160, 178 or 220 of the Penal Law or any crime defined in sections 260.32 or 260.34 of the Penal Law or any comparable offense in any other jurisdiction, the Department shall propose disapproval of such person's eligibility for employment unless the Department determines, in its discretion, that the prospective employee's employment will not in any way jeopardize the health, safety or welfare of patients, residents or clients of the provider. (i) The Department shall provide to the provider and the prospective employee, in writing, a summary of the criminal history information along with the notification identified in this paragraph. Upon the provider's receipt from the Department of a notification of proposed disapproval of eligibility for employment, the provider shall not allow the prospective employee to provide direct care or supervision to patients, residents, or clients of such provider until receipt of a final determination of eligibility for employment from the Department.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 18, 2019
Corrected date: March 18, 2019

Citation Details

Based on record review and interview during the recertification survey, the facility did not ensure 1 of 3 employees (Employee #7) who received negative determination letters from their CHRC (Criminal History Record Check) was immediately removed from direct resident care or supervision. Specifically, the facility did not remove Employee #7 from resident access when notified the employee failed the CHRC. Findings include: The facility's 11/8/2018 Criminal History Record Checks Policy (CHRC) documented a CHRC is conducted for certain prospective staff members and agency staff for employment in non-licensed positions providing direct care and/or supervision. The Proposed Disapproval Letter is sent after the criminal history record check reveals a criminal history that contains a presumed or discretionary disqualifier. Presumed disqualifiers are convictions for crimes that are specifically identified in Executive Law 845-b. A discretionary disqualifier is a conviction of a crime not listed in the statute but the conviction may result in the issuance of a proposed disapproval letter at the Department of Health's (DOH's) discretion. Upon receipt of this letter, the facility must promptly remove the staff member or agency staff from direct care or supervision of the residents. Review on 1/17/19 of a printout from CHRC, dated 1/1/19, showed documentation a Pending Denial Letter was issued to the provider on 8/10/18 for Employee #7. On 1/17/2019, the facility provided Employee #7's personnel record for review during survey. A Pending Denial Letter dated 8/10/18 was in the record and documented the employee's eligibility for employment was denied by the New York State Department of Health (NYSDOH). On 1/17/19, Employee #7's job description as a certified nurse aide (CNA) was reviewed and documented the employee was responsible for providing direct nursing and personal care support to residents. The CNA assisted residents with tasks such as bathing, dressing and toileting. Review on 1/17/19 of a Supervision of Temporary/Provisional Staff Form for 8/1 through 8/14/18 documented Employee #7 worked 2 days (8/13 and 8/14/18) after the facility received the Pending Denial Letter. On 1/17/19 at 2:40 PM, the Human Resources Director stated in an interview the purpose of fingerprinting employees was ensure employees did not have a criminal background and they were safe to work with the residents. She was responsible to check negative determinations daily, she did not have a system in place to check on the weekends. When a Pending Denial Letter was received, she was responsible to ensure an employee was removed from direct care immediately. She stated Employee #7's letter was dated 8/10/18 and continued to work through 8/14/18. She stated she did not recall what happened, the employee should have been pulled from direct care immediately and it was an oversight. 10NYCRR 402.7

Plan of Correction: ApprovedFebruary 12, 2019

The following actions were accomplished for the areas identified:
1) Employee #7 was terminated from employment on 8/14/18
The following corrective actions will be implemented to identify other areas that may be affected by the same practice:
a) The Human Resources Coordinator conducted an audit on 1/18/19 of all provisional employee CHRC correspondences and determined 100% compliance with all employees.
b) Human Resources staff will be reeducated by the Assistant Administrator on employee prescreening of potential new hires and notices on current employees identified by the CHRC Nurse Aide registry or other state registry to verify changes in credential status.
c) A second person (Human Resources Assistant) will have access requested for the CHRC system as a back up to the Human Resources Coordinator for the daily checking of the CHRC system.
d) The Human Resources staff will be reeducated by the Assistant Administrator on procedure for daily checking of the CHRC system prior to conclusion of the work day. Any negative findings will be reported immediately to the Administrator and removal of staff will be handed promptly.
The following system changes will be implemented by the Human Resources Coordinator to assure continuing compliance with regulations:
a) The Human Resources team will incorporate discussion of employee?s CHRC status at the daily onboarding and staffing meeting with inclusion of this review on the onboarding spreadsheet maintained by HR.
b) A Human Resource Compliance Review Check List will be developed by the Human Resource Coordinator to include the processing and review of all CHRC notices impacting employment status. All CHRC notices will be reviewed by Administrator upon receipt.
c) The Assistant Administrator will conduct a weekly audit x 3 months and monthly thereafter of the Human Resource Compliance Review Check List and CHRC Notices to verify all employees have been processed as per CHRC letter determination. Audit results will be reviewed with the Human Resource Coordinator for correction if required.
d) The Assistant Administrator will in-service Human Resource personnel on the following but not limited to:
1) Regulatory Requirements for CHRC determination notices and required action for employment.
2) Use of Human Resource Compliance Review Check List and Audit process
3) Facility policy regarding employment verification and CHRC determination requirements.
The facility?s compliance will be monitored utilizing the following quality assurance system:
The Human Resources Coordinator will compile statistical data on a monthly basis from the Human Resource Compliance Review Check List audits. Trend analysis data will be presented monthly for six months to the Operational QAPI Committee by the Human Resources Coordinator for evaluation and recommendations for improvement as needed.

Primary Responsible Individual: Human Resources Coordinator, Administrator, Assistant Administrator, Human Resource Assistant and QAPI Team.

Completion of this corrective action will be fully implemented by 3/18/2019.

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 18, 2019
Corrected date: February 22, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility did not ensure each resident received adequate supervision with use of assistive devices to prevent accidents for 1 of 2 residents (Resident #156) reviewed for accidents. Specifically, Resident #156 had a history of [REDACTED]. Findings include: Resident #156 was admitted [DATE] and had [DIAGNOSES REDACTED]. The 12/21/18 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, required extensive assistance of one person for transfers, limited assistance of one person for walking and locomotion on the unit, and was dependent on staff for locomotion off the unit. The resident utilized a wheelchair and walker, was not steady when moving from a seated to standing position and for surface to surface transfers. The resident had 3 or more falls with and without injury since the prior assessment. Accident and Incident reports from 9/6/18 through 1/13/19 documented the resident had 10 unwitnessed falls due to self-transferring and ambulating without asking for assistance. The physical therapy plan of care documented the resident received therapy from 11/28/18 through 12/26/18 for muscle weakness and unsteadiness on feet. The physical therapy (PT) daily treatment note dated 11/28/18 documented recommendations and education for nursing staff. The PT recommended locomotion on the unit, in the wheelchair with leg rests removed for propulsion with lower extremities and increasing positioning in line of sight for reducing fall risk. The comprehensive care plan (CCP) updated 11/28/18 documented the resident was at risk for falls and the resident was to have wheelchair leg rests removed for propulsion with her lower extremities. Nursing progress notes documented on 12/27/18, the resident was self-transferring in and out of bed, using the wheelchair to self-propel on the unit. The Fall Scale assessment dated [DATE] documented the resident had a history of [REDACTED]. The resident's score indicated a high risk for falling. The nursing progress note dated 1/15/19 documented the resident was noted to have anxiety, kept switching from walker to wheelchair, was self-transferring in her room all shift, was restless, and was running into walls and doorways when self-propelling. The Kardex report printed 1/17/19 documented the resident had safety interventions including for locomotion on the unit, the resident was to have limited assistance of one person, and wheelchair bilateral leg rests were to be removed for propulsion with her lower extremities. The resident was observed in her wheelchair with the leg rests in place: - On 1/15/19 from 12:19 PM to 12:55 PM, self-propelling from the dining room to her room using doorways and handrails to assist, her feet were observed under the foot plates of the leg rests as she attempted to move the wheelchair; - On 1/15/19 at 5:08 PM, in the unit hall, her feet were under the foot plates of the leg rests of the wheelchair as she self-propelled; - On 1/15/19 at 5:50 PM, at a table in the dining room, she stood from the wheelchair and moved to the other side of the table as she held the back of a stationary chair; - On 1/16/19 from 4:17 to 4:22 PM, in the hall, her feet under the foot plates of the leg rests as she self-propelled; and - On 1/17/19 from 9:21 to 9:30 AM and at 4:13 PM in the unit hall, self-propelling slowly with her feet under the foot plates of the leg rests. When interviewed on 1/17/19 at 3:48 PM, the Director of Therapy stated any resident who self-propelled in a wheelchair with their legs and feet should not have leg rests on the chair due to the risk to fall and impeding mobility. During an interview on 1/17/19 at 4:00 PM, physical therapist #9 stated he added the instructions to the resident's care plan to remove the leg rests from the wheelchair when the resident was utilizing her wheelchair on the unit. He stated there were multiple safety concerns including poor safety awareness, attempts to self-transfer, and impaired judgment. The resident was referred to PT due to multiple falls and she was at risk for falls if the leg rests were on her wheelchair. The resident was not able to manipulate the leg rests to safely transfer in or out of her wheelchair. Certified nurse aide (CNA) #11 stated during an interview on 1/18/19 at 10:30 AM the resident was a high risk for falls, transferred herself into or from the wheelchair all the time, and did not ask for assistance. She utilized the wheelchair for mobility on the unit, self-propelled with her legs and feet, and was unable to manipulate the leg rests. The CNA stated the leg rests were to be removed when the resident was on the unit, and placed on the chair for transport off the unit. She could not recall if the resident had the leg rests on the chair the past 4 days nor the reason they would be left on her chair while the resident remained on the unit. When interviewed on 1/18/19 at 1:15 PM, registered nurse (RN) Unit Manager #10 stated the resident was at risk for falls due to multiple prior falls, standing and transferring from her wheelchair without asking for assistance, and poor safety awareness. The resident should not have leg rests on her wheelchair unless she was taken off the unit by staff and they should be removed when returned. She self-propelled in her wheelchair, she was unable to manipulate the leg rests herself, and they could cause her to fall if she stood from her chair. 10 NYCRR 415.12(h)(2)

Plan of Correction: ApprovedFebruary 11, 2019

On 2/4/19 Resident #156 had a care plan change to state foot pedals only on when staff assisting in locomotion off unit, once at desired location, foot pedals to be removed.
All residents plans of care were reviewed to insure fall prevention devices were care planned and had clear instructions regarding application and time.
All CNA's were re-educated on the use of all fall prevention devices. A sample of 5 residents per unit per week will be audited for a total of 25 residents audited weekly. The resident devices will be audited to insure proper placement by Unit Managers weekly for four weeks then monthly for two months.
The DON is responsible for monitoring this education and assessing the adherence to this policy monthly via QAPI.
The results will be reported at the monthly QAPI Meeting for three months by the DON or until 100% compliance is achieved.

FF11 483.45(g)(h)(1)(2):LABEL/STORE DRUGS AND BIOLOGICALS

REGULATION: §483.45(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. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(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. §483.45(h)(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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 18, 2019
Corrected date: February 22, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey, the facility did not label and maintain drugs and biologicals in accordance with currently accepted professional principles. Specifically, 3 of 5 medication carts reviewed had open, unlabeled medications that have shortened expiration dates once opened. (ProSource, a protein supplement). Findings Include: The facility's policy, Medication Label and Container Requirements, dated 5/30/18, did not address the labeling of stock medication. On 1/15/19 at 2:29 PM, the south unit medication cart 1 was reviewed with licensed practical nurse (LPN) #1. The following was observed: - One bottle of ProSource was opened and undated. The ProSource label contained the instructions to discard three months after opening. - One multi-dose vial of [MEDICATION NAME] 1% (local anesthetic) was opened and undated. On 1/15/19 at 2:33 PM, LPN #1 was interviewed and stated if she saw an undated open medication, she would discard the bottle and get a new one from the medication room. Once a medication was opened it was supposed to be labeled with a date. On 1/15/19 at 2:50 PM, the 3rd floor short hall medication cart was reviewed with LPN #2. One bottle of ProSource was observed open and undated. The ProSource label contained instructions to discard three months after opening. On 1/15/19 at 2:55 PM, LPN #2 was interviewed and stated medications should be labeled with a date when opened. On 1/15/19 at 3:00 PM the 2nd floor medication cart was reviewed with LPN #3, and one bottle of ProSource was observed open and undated. The ProSource label contained the instructions to discard three months after opening. On 1/15/19 at 3:00 PM, LPN #3 was interviewed and stated the medication should be labeled with a date when opened. During an interview on 1/18/19 at 10:30 AM, registered nurse (RN) Unit Manager #4 stated medications must be labeled with a date and she was unaware of the reason they were not. She stated that the [MEDICATION NAME] should have been dated. During an interview 1/18/19 at 1:19 PM, RN Unit Manager #5 stated his expectations were nurses write the date on the medications when they were opened. During an interview on 1/18/19 at 1:24 PM, RN Unit Manager #6 stated she expected staff to date the medications when they were opened. She stated she provided the nurses on her unit with on-going education regarding length of time medications were good and which medications must be dated. During an interview on 1/18/19 at 1:29 PM, the Director of Nursing (DON) stated the ProSource and the [MEDICATION NAME] should have been dated. 10 NYCRR 415.18(d)

Plan of Correction: ApprovedFebruary 11, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** All open Prosource bottles and [MEDICATION NAME] vials were discarded on (MONTH) 18th, 2019.
On 2/5/19 the Medication Cart Policy was updated to state All medications requiring date when opened will be properly labeled and discarded according to the manufacturer's recommendation.
All Medication Carts were audited to insure adherence to this policy/procedure by 1/21/19.
All licensed staff will be educated on the Medication Cart Policy by 2/22/19.
The DON is responsible for monitoring this education and assessing the adherence to this policy monthly via the QAPI Meeting for three months.
All Medication Rooms/Carts will be audited by the Unit Managers weekly to insure adherence to this policy.
The Medication Rooms/Carts will be audited monthly by the Pharmacy Consultant to insure adherence to this policy.
The results will be reported at the Monthly QAPI Meeting for three months by the DON, or until 100% compliance is achieved.

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS

REGULATION: Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2019
Corrected date: March 18, 2019

Citation Details

Based on observation and interview conducted during the Life Safety Code survey, the facility did not properly maintain electrical installations for two isolated areas (first floor storage room adjacent to the rear elevators and the clean utility room adjacent to the first floor nurses station). Specifically, there were two unapproved electrical power strips in use with Patient Care Related Electrical Equipment (PCREE) plugged into them. Findings include: 1) When observed on 1/15/2019 at 12:45 PM, there was an unapproved 12-way electrical power strip mounted on the wall in use and charging PCREE within the first floor storage room adjacent to the rear elevators. Specifically, there were two feeding pumps and four IV pumps plugged into the electrical power strip. When interviewed on 11/5/2019 at 12:45 PM, the Director of Maintenance stated he was not sure if the power strip was approved for use with PCREE. 2) When observed on 1/15/2019 at 4:42 PM, there was an unapproved 6-way electrical power strip in use and charging PCREE within the clean utility room adjacent to the first floor nurses station. Specifically, there were two lift batteries plugged into the electrical power strip. When interviewed on 1/15/2019 at 4:42 PM, the Director of Maintenance stated he did not realize PCREE could not be plugged into the power strip. 2012 NFPA 99: 10.2.4 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedFebruary 11, 2019

The following corrective actions will be implemented to maintain compliance with this NFPA standard. In the first floor storage room adjacent to the rear elevators patient care related electrical equipment (PCREE) was removed immediately from the power strip for charging and the power strip was removed from the location on 2/11/19. (2) Approved power strip(s) UL 1363A were installed temporarily in anticipation of an electrician to install (10) new hospital grade quad surface mount outlets for charging of PCREE. Quote obtained by Bouille Electric on 2/5/2019 for install. In the clean utility room adjacent to the first floor nurses station (North unit) patient care related electrical equipment (PCREE) was removed from the power strip for charging and the power strip was removed from the location on 1/08/19. Elderwood Maintenance department installed (1) hospital grade quad surface mount outlet for charging of PCREE on 2/6/2019. Facility inspection of all storage and clean utility rooms were performed to identify similar use of unapproved power strips for PCREE charging. Inspection performed identified all remaining areas were in compliance with no corrective action required. A quarterly inspection of storage and clean utility rooms will occur for compliance with NFPA 101 regulation by the Elderwood at Waverly facility Maintenance department. Personnel will document compliance with regulation and/or any necessary corrective actions at time of inspection. Review of quarterly inspection will be performed by the Director of Maintenance following its completion as part of routine monthly departmental quality assurance process. Findings are reported during the Life Safety portion of Risk Management committee monthly for 3 months to ensure compliance. Director of Maintenance is responsible for the correction of deficiency K920. Corrective action began on 1/08/19 with removal of the power strips. Electrician quoted install of outlets in storage room on 2/5/2019 and will be on site to correct by 3/18/2019. North clean utility room was corrected with no remaining corrections required as of 2/6/2019.

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2019
Corrected date: February 15, 2019

Citation Details

Based on record review and interview conducted during the Life Safety Code survey, the facility did not follow manufacturer's inspection and maintenance recommendations for 1 of 4 Patient Care Related Electrical Equipment (PCREE) in accordance with National Fire Protection Agency (NFPA) 99 for a Welch Allyn vital signs monitor. Specifically, the facility did not follow the preventative maintenance guidelines set forth by the manufacturer for the Welch Allyn vital signs monitor. Findings include: Review on 1/17/2019 of the facility's preventative maintenance program policy, dated 10/12/2018, revealed under the procedure section An inspection checklist will be developed for all equipment. Inspections will be scheduled routinely, minimally according to manufacturer's recommendations and/or per identified facility needs, for periodic maintenance check. Review on 1/17/2019 of the facility's third party preventative maintenance inspection reports, dated 11/8/2018, revealed the Welch Allyn vital signs monitors were being inspected annually and did not indicate what was specifically inspected at the time of inspection. Review on 1/17/2019 of the Welch Allyn vital signs monitor users manual revealed every 3 months, inspect the temperature probe, SpO2 cord, and accessories for fraying or other damage. When interviewed on 1/17/2019 at 10:00 AM, the Director of Maintenance stated he did not know the vendor was not following manufacturer maintenance recommendations. 2012 NFPA 99: 10.5.3 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedFebruary 11, 2019

The following corrective action will be implemented to maintain compliance with this NFPA standard. The manufacturer?s instruction for the(NAME)Allyn Spot Vital Signs LXi states ?Every three months, inspect the blood pressure cuff, SPO2 cable, and other accessories for fraying or other damage. Replace as necessary. Only an individual specifically trained and approved for repair and/or verification of this specific(NAME)Allyn product may perform maintenance procedures specifically described in this manual. For service, refer the device to an Authorized Service Center.? A quarterly preventative maintenance inspection was developed to include inspection of the blood pressure cuff, SPO2 cable, and other accessories for fraying or other damage. In addition, Zoetek will continue to perform an annual electrical inspection of the device(s). A Process for inventory of devices will be maintained to include PM inspection due dates. A quarterly PM inspection will be implemented according to the manufactures guidelines to maintain compliance with NFPA 101 regulation by the Elderwood at Waverly facility Maintenance department. Personnel will document compliance with regulation and/or any necessary corrective actions at time of inspection. Review of quarterly inspection will be performed by the Director of Maintenance following its completion as part of routine monthly departmental quality assurance process. Findings are reported during the Life Safety portion of Risk Management committee monthly for 3 months to ensure compliance. Director of Maintenance is responsible for the correction of deficiency K921. Corrective action began on 1/10/19 with review of PM process with Zoetek and further review of the manufacturer?s guidelines. New PM tool developed on 2/6/19 and(NAME)Allyn Spot Vital Signs LXi inspection to be completed and documented by 2/15/19.

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 17, 2019
Corrected date: March 18, 2019

Citation Details

Based on observation and interview conducted during the Life Safety Code survey, the facility did not ensure 2 of 2 emergency generator remote annunciators were properly installed, as required. Specifically, there were no remote annunciator panels for the 55 kilowatt (kW) and 150 kW emergency generators installed within the facilty in areas that had 24-hour staff coverage. Findings include: When observed between 1/15/2019 and 1/17/2019, there were no remote alarm annunciator panels installed within the facility. When interviewed on 1/15/2019 at 12:30 PM, the Director of Maintenance stated there was no remote annunciator panels installed within the building and they were working on getting them installed. 2012 NFPA 99: 6.4.1.1.17 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedFebruary 11, 2019

The following correction action will be implemented to maintain compliance with NFPA 101 Essential Electric System. Penn Power was selected to install (2) generator annunciator panels. Quoting of project occurred on 1/28/19. Annunciator panel 1 (towers generator) will be installed on the 2nd floor unit nursing station area which has 24-hour staff coverage. Annunciator panel 2 (North/South Generator) will be installed on the South unit nursing station area which has 24-hour staff coverage. Training of annunciator alarms and expectations of response will be performed with all employees upon installation and no later than 3/18/19. Penn Power will provide semi-annual inspection of the annunciator panel to include review of functionality and other requirements per the manufacturer?s instructions. Documentation of Penn Power inspections will be maintained by the Elderwood Maintenance department. During the monthly load test of the generators visual inspection of the annunciator panels will be performed to verify operating condition and documented by the Elderwood maintenance department. This will be reported in the Risk Management committee monthly for 3 months to ensure compliance. The Director of Maintenance in coordination with Elderwood Administrative Services is responsible for correction action of K916. Penn Power is installing the annunciator panels by 3/18/19.

K307 NFPA 101:GAS AND VACUUM PIPED SYSTEMS - INFORMATION AN

REGULATION: Gas and Vacuum Piped Systems - Information and Warning Signs Piping is labeled by stencil or adhesive markers identifying the gas or vacuum system, including the name of system or chemical symbol, color code (Table 5.1.11), and operating pressure if other than standard. Labels are at intervals not more than 20 feet, are in every room, at both sides of wall penetrations, and on every story traversed by riser. Piping is not painted. Shutoff valves are identified with the name or chemical symbol of the gas or vacuum system, room or area served, and caution to not use the valve except in emergency. 5.1.14.3, 5.1.11.1, 5.1.11.2, 5.2.11, 5.3.13.3, 5.3.11 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2019
Corrected date: February 15, 2019

Citation Details

Based on observation, interview, and record review during the Life Safety Code survey, the facility did not maintain the piped medical gas (oxygen) and vacuum system in accordance with National Fire Protection Association (NFPA) 99 - Standard for Health Care Facilities section/table 5.1.11.1.2 which states Pipe labels shall be located as follows: At intervals of not more than 6.1 m (meter) (20 feet), at least once in or above every room, on both sides of walls or partitions penetrated by the piping, and at least once in every story height traversed by risers. Specifically, the piping serving the medical oxygen system was not labeled throughout the north and south wings of the second floor rehab unit. Findings include: When observed on 1/16/2019 between 2:10 PM and 2:30 PM, there was no labeling on the piping for the medical oxygen system throughout the second floor rehab unit, as required. Specifically, when inspecting above corridor and patient room ceiling tiles within both north and south wings of the second floor rehab unit, there was no evidence that the piped medical oxygen system was labeled according to code requirements. When interviewed on 1/16/2019 at 2:30 PM, the Director of Maintenance stated he was unaware the piping for the oxygen system was not labeled. Record review of the facility's most recent third party Med/Gas annual inspection dated 12/17/2018 revealed there was no evidence the piping for the medical oxygen system was checked or inspected. 2012 NFPA 99 5.1.11.1.2 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedFebruary 11, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Approved Green and White Oxygen labels with arrowed direction were purchased by the facility. Labels will be affixed to Oxygen piping on north and south hallways of the second floor following NFPA 99 guidelines of Pipe labels shall be located as follows: At intervals of not more than 6.1 m (meter) (20 feet), at least once in or above every room, on both sides of walls or partitions penetrated by the piping, and at least once in every story height traversed by risers. Facility inspection of all oxygen piping will be completed. This includes Main lobby, administrative hallway, and rehabilitation areas of first floor where piping runs to exterior of building. Where required, green and white oxygen labels with arrowed direction will be affixed to oxygen piping following NFPA 99 guidelines of ?Pipe labels shall be located as follows: At intervals of not more than 6.1 m (meter) (20 feet), at least once in or above every room, on both sides of walls or partitions penetrated by the piping, and at least once in every story height traversed by risers. Development of an annual inspection of oxygen piping will occur for label compliance with NFPA (99) regulation by the Elderwood at Waverly facility Maintenance department. Personnel will document compliance with regulation and/or any necessary corrective actions at time of inspection. Review of annual inspection will be performed by the Director of Maintenance following its completion as part of routine monthly departmental quality assurance process. Findings are reported annually during the Life Safety portion of Risk Management committee to ensure compliance. Director of Maintenance is responsible for the correction of deficiency K909. Corrective action began on 1/22/19 with the purchase of Oxygen labels. First floor labeling was completed on 1/29/19. Additional labels ordered on [DATE] and received on 2/4/19. Remaining labeling to be completed by 2/15/19. Annual inspection to be documented upon completion by 2/15/19.