Willow Point Rehabilitation and Nursing Center
April 4, 2019 Certification 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: April 5, 2019
Corrected date: June 4, 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 ensure it 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 5 (Resident #585) residents reviewed for respiratory care. Specifically, Resident #585 was on droplet precautions (an infection control procedure to reduce the risk of exposure of infectious agents to others) and multiple staff were observed entering the room without appropriate personal protective equipment (PPE, barriers such as gloves, mask, or gown). Findings include: The 5/2018 facility policy, Infection Control - Transmission-Based Precautions (Isolation), documented isolation precautions would be put in place when a resident showed signs of an infection that could be transmitted to others. Categories listed included droplet precautions, used when respiratory droplets could contain bacteria or viruses that could spread to others. A face mask was to be used when entering the room, with additional PPE used as necessary. Resident #585 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 3/29/19 Minimum Data Set (MDS) assessment documented the resident had intact cognition and required assistance of 1-2 staff with all activities of daily living (ADLs) except eating. The 3/2019 physician's orders [REDACTED]. The 3/30/19 lab report documented moderate growth of [MEDICAL CONDITION] (MRSA, a bacterium that is resistant to many antibiotics). The certified nurse aid (CNA) care instructions (Kardex), dated 4/4/19, documented the resident was placed on droplet isolation precautions 3/28/19. The following observations were made: - On 4/1/19 at 10:42 AM there was no isolation cart observed outside of Resident #585's room. At 11:04 AM licensed practical nurse (LPN) #1 stated Resident #585 was on droplet isolation. A yellow isolation cart was observed outside of Resident #585's room. - On 4/1/19 at 11:21 AM a small, yellow isolation magnet was placed on the door frame of the resident's room. - On 4/1/19 at 12:39 PM the resident was eating lunch in his room with a visitor and the visitor was not wearing a mask. - On 4/3/19 at 10:28 AM unit helper #3 was in the resident's room passing a morning snack and not wearing PPE. The door magnet and PPE cart were observed outside of the room. - On 4/3/19 at 10:35 AM the resident's roommate was sitting in his wheelchair next to his bed with the privacy curtain between the resident areas open. - On 4/3/19 at 11:50 AM the resident was in bed, watching TV. His roommate was in his wheelchair with the privacy curtain open between the resident areas. - On 4/4/19 09:17 AM CNA #4 was in the resident's room, setting up his breakfast tray and was not wearing a mask or gloves. The isolation magnet and PPE cart were observed outside the room. During an interview on 4/4/19 at 1:03 PM unit helper #3 stated she would know when a resident was on isolation precautions when there was a magnet on the door and the type of isolation was documented on a laminated paper in the top drawer of the isolation cart. Droplet precautions required the use of a mask and gown, which should be worn every time the room was entered. She stated if she was going to see the roommate she would still wear a mask. She reported she did not see the isolation sign on the door until she was exiting the room. During an interview on 4/4/19 at 1:16 PM LPN #5 stated the provider would make the decision to place a resident on isolation precautions. Resident #585's culture results were received over the weekend (3/30/19), the Infection Control Nurse (ICN) was consulted, and the doctor was made aware on 4/1/19. She stated Resident #585 was put on droplet precautions due to bacterial pneumonia. Standard droplet isolation consisted of a mask, and gloves or gown depending on what was being done in the room. She stated a mask should also be worn to provide care to the roommate. During an interview on 4/4/19 at 1:26 PM registered nurse (RN) Unit Manager #2, stated her expectations for droplet isolation was at the very least, a mask. If staff were going to touch a resident's personal belongings they should wear gloves, and if physical contact was expected, a gown should be worn. Staff were made aware a resident was on isolation through the kiosk (computer terminal and program where CNAs documented) or on the Kardex (care instructions). Staff that were floated to the unit would be expected to check the kiosk when they arrived on the floor and familiarize themselves with the residents. Since Resident #585's roommate did not have an infection, the privacy curtain should remain closed between the resident areas, and there should be at least three feet between the residents. During an interview on 4/4/19 at 2:53 PM the Infection Control Nurse stated an order from a provider was not required to place a resident on isolation precautions, and the type of bacteria that caused the infection did not affect the droplet precaution procedure. She reported when a resident on droplet precautions had a roommate that was not on isolation precautions, the privacy curtain between them should remain closed. She explained if a staff member was going to provide care to a resident on droplet precautions a gown, gloves, and mask should be used. If assisting with meal tray set-up, gloves and a mask should be used. A mask should always be worn when entering the room. She stated staff needed to be re-educated on PPE, and the privacy curtain should have been closed between the residents. 10NYCRR 415.19 (a)(2)

Plan of Correction: ApprovedApril 24, 2019

1. Resident #585 is no longer on droplet precautions.
2. All residents have been identified as potentially being affected by the same practice. A full house review of all residents on isolation precautions was performed to ensure proper PPE was present.
3. The Director of Nursing, Medical Director, Infection Control Nurse, and Administrator will continue to review and revise, as needed, policies and procedures related to infection control precautions.
Education was provided to all part and full time staff regarding infection control precautions. Educational emphasis was placed on identifying infection control precaution type and necessary PPE.
4. The Facility developed an audit tool to monitor compliance with facility policies and procedures related to infection control precautions. Facility Clinical Care Coordinators or designees will conduct 20 audits per week for proper infection control procedures and appropriate PPE and report findings to the Director of Nursing. Corrective action will be implemented as indicated.
The Director of Nursing or designee will report audit findings to the Quality Assurance/Process Improvement Committee monthly for three months for evaluation and follow-up with a compliance goal of 90%. At the end of the three-month period the committee will evaluate the need for additional monitoring or other corrective actions. Ad Hoc meetings will be convened as needed.
5. Responsibility: Director of Nursing.

FF11 483.70(a)-(c):LICENSE/COMPLY W/ FED/STATE/LOCL LAW/PROF STD

REGULATION: §483.70(a) Licensure. A facility must be licensed under applicable State and local law. §483.70(b) Compliance with Federal, State, and Local Laws and Professional Standards. The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. §483.70(c) Relationship to Other HHS Regulations. In addition to compliance with the regulations set forth in this subpart, facilities are obliged to meet the applicable provisions of other HHS regulations, including but not limited to those pertaining to nondiscrimination on the basis of race, color, or national origin (45 CFR part 80); nondiscrimination on the basis of disability (45 CFR part 84); nondiscrimination on the basis of age (45 CFR part 91); nondiscrimination on the basis of race, color, national origin, sex, age, or disability (45 CFR part 92); protection of human subjects of research (45 CFR part 46); and fraud and abuse (42 CFR part 455) and protection of individually identifiable health information (45 CFR parts 160 and 164). Violations of such other provisions may result in a finding of non-compliance with this paragraph.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 2019

Citation Details

Based on observation and staff interview during the recertification survey, carbon monoxide detection was not provided in compliance with Federal, State, and Local Laws and Professional Standards. The International Fire Code, (YEAR) Edition Section 915 Carbon Monoxide Detection (adopted by New York State), requires carbon monoxide detection in all areas with fuel burning/gas operated equipment. Specifically, carbon monoxide detection was not installed in the basement level where there was fuel burning equipment. Findings include: When observed between 4/1/2019 and 4/4/2019 there was no carbon monoxide detection installed throughout the basement level of the facility which contained three furnace rooms with fuel burning equipment, three generator rooms with natural gas generators, the main laundry room with fuel/gas burning appliances, and a main kitchen fuel/gas burning appliances (gas dryers). When interviewed on 4/4/2019 at 10:30 AM, the Facility Manager stated there was no carbon monoxide detection installed anywhere in the facility. He was unaware of the code requirements for the placement of the detectors. 2012 NFPA 101: 2.2 2012 NFPA 720 2015 International Fire Code, Section 915 483.70 (b) 10NYCRR 400.2

Plan of Correction: ApprovedApril 24, 2019

1. Carbon monoxide detectors were placed throughout the basement level of the facility which contain three furnace rooms with fuel burning equipment, three generator rooms with natural gas generators, the main laundry room with fuel/gas burning appliances, and a main kitchen with fuel/gas burning appliances.
2. All residents have been identified as potentially being affected by the same practice. A full house review of all facility areas with fuel burning/gas operated equipment was conducted to evaluate need for carbon monoxide detection.
3. The Facility Manager and Administrator will continue to review and revise, as needed, policies and procedures related to carbon monoxide detection.
Education was provided to all part and full time staff regarding carbon monoxide detection. Educational emphasis was placed on identifying carbon monoxide alarms and correct response when a carbon monoxide detector alarms.
4. The Facility developed an audit tool to monitor compliance with facility policies and procedures related to carbon monoxide detection. The Facilities Manager or designee will audit all carbon monoxide detectors monthly for proper functioning for three months and report findings to the Administrator. Corrective action will be implemented as indicated.
The Administrator or designee will report audit findings to the Quality Assurance/Process Improvement Committee monthly for three months for evaluation and follow-up with a compliance goal of 90%. At the end of the three-month period the committee will evaluate the need for additional monitoring or other corrective actions. Ad Hoc meetings will be convened as needed.
5. Responsibility: Administrator.

FF11 483.10(c)(7):RESIDENT SELF-ADMIN MEDS-CLINICALLY APPROP

REGULATION: §483.10(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the recertification survey, the facility did not ensure the self-administration of medications was clinically appropriate for 1 of 1 resident (Resident #137) reviewed for self-administration of medications. Specifically, Resident #137 self-administered a topical medication, was not assessed for the ability to self-administer medications and did not have a physician order [REDACTED]. Findings include: The facility's Medication Self-Administration policy dated 2/6/19 documented: - A resident may self-administer medication only when a physician specifies with a written order that the medication may be kept at the bedside. - Residents who self-administer medication are responsible for storing them securely in a locked drawer. - Self-medication pertains primarily to [MEDICATION NAME], eye drops, nasal sprays, creams, and ointments. - The nurse on the unit will review with the resident the rules for self-administration of medications and both will sign the Medication Self-Administration Agreement. A copy of the agreement is to be kept in the medication administration record (MAR) with a self-administration flag. - Any medication the resident self-administers will be clearly marked on the MAR. - The nurse will monitor and document the resident's ability of self-administration of medication each shift for 7 days; documentation beyond 7 days will occur as needed. Resident #137 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 2/14/19 Minimum Data Set (MDS) assessment documented the resident had intact cognition, rejected care 1 to 3 days of the assessment period, and required extensive assistance of one staff for dressing and hygiene. The comprehensive care plan (CCP) initiated 10/24/19 documented the resident was at risk for pain related to rib fractures, [MEDICATION NAME] disc disorder, and lumbar fracture. Interventions included to administer [MEDICATION NAME] as per orders. There was no documented evidence of Resident #137's self-administration of a topical pain treatment. The physician's orders [REDACTED]. The physician's orders [REDACTED]. There was no documented evidence of an order for [REDACTED]. Nursing progress notes from 1/1/19 - 4/3/19 contained no documentation regarding the resident self-administering the muscle rub cream, monitoring of its use, or of his ability to self-administer and keep the cream in his room. There was no documented evidence of a Medication Self-Administration agreement. The Medication Administration Records (MAR) for 1/2019, 2/2019, 3/2019 and 4/2019 did not include directions for the resident to self-administer the muscle rub. The 1/2019 MAR documented the as needed muscle rub cream was administered by a licensed practical nurse (LPN) on 1/12/19 and 1/31/19. The 2/2019 MAR documented the as needed muscle rub cream was administered by an LPN on 2/2/19 and 2/16/19. The 3/2019 and 4/2019 MARs documented there were no as needed (prn) administrations of the muscle rub cream and no documentation of a self-administered muscle rub cream. During an interview with the resident on 4/1/19 at 11:00 AM, he stated he often applied the muscle rub cream on his knee, he was unsure how much he used or how often he used it and stated he always kept it on his overbed table or nightstand. The following observations were made in the resident's room: - On 4/1/19 at 11:00 AM, a nearly full tube of muscle rub cream was on the resident's overbed table, the tube was not labeled with a name or date. - On 4/2/19 at 9:28 AM, an unlabeled tube of muscle rub cream was on the nightstand by the bed. - On 4/3/19 at 10:01 AM and at 1:45 PM, the resident was in bed, an unlabeled tube of muscle rub cream was on the nightstand and the top 1/4 of the tube was flattened/empty. - On 4/4/19 at 10:50 AM, a tube of unlabeled muscle rub cream was on the nightstand and 1/2 of the tube was flattened/empty. - On 4/5/19 at 9:50 AM, the resident was in bed, a nearly empty (almost entirely flattened) unlabeled tube of muscle rub cream was on the overbed table. During an interview on 4/5/19 at 9:55 AM, certified nurse aide (CNA) #7 stated she routinely cared for the resident, often saw the muscle rub cream in his room and was unsure who applied it. On 4/5/19 at 10:07 AM, LPN #8 stated during an interview she was unaware if the resident used any topical ointments or creams, she had not applied muscle rub, and the resident had not called her to apply muscle rub cream. She stated typically, creams or ointments had an order and LPNs applied them. Residents who self-administered medications were to have a physician's orders [REDACTED]. The LPN looked in the MAR and confirmed the resident had an order for [REDACTED]. When interviewed on 4/5/19 at 10:22 AM, registered nurse (RN) Unit Manager #9 stated she was unaware the resident had muscle rub cream in his room and was administering it himself. She stated there should be an order if he was using it independently and the tube should be labeled with his name and date it was opened for nursing to monitor his usage. She stated there should also be an agreement the resident signed to keep the rub in his room and use it and there was not. 10NYCRR 415.3(e)(1)(vi)

Plan of Correction: ApprovedApril 24, 2019

1. Topical medication for Resident #137 was removed from the room. He was assessed and determined not appropriate to self-administer medications.
2. All residents have been identified as potentially being affected by the same practice.
A full house review of all residents receiving a topical medication was completed to assess for ability to self-administer medications. All rooms where visually checked to ensure no topical medications were in the room against facility policy.
3. The Director of Nursing, Medical Director, and Administrator will continue to review and revise, as needed, policies and procedures related to self-administration of medication.
Education was provided to all part and full time staff regarding facility policies and procedures related to self-administration of medications. Educational emphasis was placed on not leaving topical medications at bedside without a physician?s order to self-administer.
4. The Facility developed an audit tool to monitor compliance with facility policies and procedures related to self-administration of medications. Facility Clinical Care Coordinators or designees will audit 20 residents with topical medications per week for 12 weeks and report findings to the Director of Nursing. Corrective action will be implemented as indicated.
The Director of Nursing or designee will report audit findings to the Quality Assurance/Process Improvement Committee monthly for three months for evaluation and follow-up with a compliance goal of 90%. At the end of the of the three-month period the committee will evaluate the need for additional monitoring or other corrective actions. Ad Hoc meetings will be convened as needed.
5. Responsibility: Director of Nursing.

FF11 483.25(i):RESPIRATORY/TRACHEOSTOMY CARE AND SUCTIONING

REGULATION: § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 5, 2019
Corrected date: June 4, 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 ensure that each resident received the proper respiratory treatment and care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 4 (Resident #216) residents reviewed for respiratory care. Specifically, Resident #216 was observed receiving oxygen and did not have a physician order or a care plan for oxygen. Findings include: The facility's policy for administration of oxygen, dated 4/2014, included: - A physician's order for oxygen must include specific liter flow/minute, mode of delivery (cannula/mask), parameters for use (as needed or continuous) and reason/[DIAGNOSES REDACTED]. Resident #216 was readmitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 3/4/19 Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired, she required extensive to total assistance with activities of daily living and she did not use oxygen while a resident at the facility. The 2/25/19 hospital discharge summary documented the resident was admitted to the hospital with [REDACTED]. The 2/25/19 registered nurse (RN) facility admission screening, completed by RN #10, documented the resident's vital signs were stable, her oxygen saturation was 98% (normal 91-100%) and she received oxygen via a mask. There was no documentation of the liter flow rate of the oxygen. The 2/25/19 physician's orders did not include an order for [REDACTED]. The 2/25/19 through 4/3/19 nursing progress notes did not document the resident was on oxygen. The Medication Administration Record [REDACTED]. The resident's comprehensive care plan, revised on 3/28/19, did not document a plan or interventions for oxygen use. The resident was observed: - On 4/1/19 at 10:50 AM, in bed sleeping, wearing oxygen and coughing. - On 4/2/19 at 8:54 AM, in bed on her back, the oxygen nasal cannula was not in her nose and was lying on the bed. The resident was snoring/wheezing. - On 4/4/19 at 9:36 AM, oxygen nasal cannula was in place and the resident was coughing and at 12:10 PM the resident was in bed with oxygen on at 2 liters. On 4/4/19 at 12:18 PM, RN #10 stated in an interview when someone was admitted from the hospital on oxygen it was reconciled during the admission process, and an order would be obtained at that time. She stated licensed practical nurse (LPN) #11 would have been responsible as she was the admissions nurse. She stated she recalled the resident returning from the hospital on oxygen, she did not see a current order for oxygen in the resident's record and an order was required. Oxygen use should be in the care plan and she was not sure why it was not. On 4/4/19 at 12:42 PM, LPN #11 stated in an interview she was the admission/discharge nurse for the facility and was responsible for obtaining and reviewing the packet sent from the hospital. She reviewed the hospital orders, the discharge summary and labs, and called the physician for orders. She completed the paper review of the records and another LPN or RN did the physical assessment. The nurse doing the physical assessment would be responsible to report back to her about items such as oxygen that might not have been in the hospital paperwork. She stated she did not recall the day Resident #216 was readmitted , RN #10 did the physical assessment of the resident and she was never told the resident was on oxygen. On 4/4/19 at 12:53 PM, RN #10 was re-interviewed and stated the nurse doing the physical assessment should be communicating with LPN #11 to discuss anything that was missing on the hospital paperwork. She stated she remembered speaking with LPN #11 about the resident's oxygen and it must have been missed. 10NYCRR 415.12(k)(6)

Plan of Correction: ApprovedApril 24, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident #216 was reviewed by physician and received an order for [REDACTED].
2. All residents have been identified as potentially being affected by the same practice. A full house review of all residents receiving oxygen was completed to ensure a physician?s order was in place as well as appropriate care plans.
3. The Director of Nursing, Medical Director, and Administrator will continue to review and revise, as needed, policies and procedures related to respiratory care.
Education was provided to all part and full time staff regarding facility policies and procedures related to oxygen use. Educational emphasis was placed on need for physician?s order and appropriate care plans when a resident requires oxygen.
4. The Facility developed an audit tool to monitor compliance with facility policies and procedures related to oxygen use. Facility Clinical Care Coordinators or designees will audit 20 residents per unit a month for 12 weeks and report findings to the Director of Nursing. Corrective action will be implemented as indicated.
The Director of Nursing or designee will report audit findings to the Quality Assurance/Process Improvement Committee monthly for three months for evaluation and follow-up with a compliance goal of 90%. At the end of the three-month period the committee will evaluate the need for additional monitoring or other corrective actions. Ad Hoc meetings will be convened as needed.
5. Responsibility: Director of Nursing.

Standard Life Safety Code Citations

K307 NFPA 101:EGRESS DOORS

REGULATION: Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 4, 2019
Corrected date: June 3, 2019

Citation Details

Based on observation, record review and interview during the Life Safety Code survey, the facility did not ensure 2 of 4 required emergency exit egress doors (exit access door to first floor south building and exit door #11) with locking arrangements within the memory care West building were readily able to be unlocked at all times by staff. Specifically, both doors had numeric keypads installed to release the locking arrangements for egress and were not operational when tested . 1) When observed on 4/2/2019 at 4:10 PM, the exit access door leading to first floor south building within the West building (memory care unit) had a locking arrangement and a numeric keypad that was not operational when tested . The door remained in the locked position and was not able to be readily unlocked by staff at all times. When interviewed on 4/2/2019 at 4:10 PM, the Facility Manager stated the keypad was disabled years ago to prevent staff from cutting through the West building from the South building. 2) When observed on 4/2/2019 at 4:30 PM, the exterior exit door #11 within the West building (memory care unit) had a locking arrangement and a numeric keypad that was not operational when tested . The door remained in the locked position and was not able to be readily unlocked by staff at all times. When interviewed on 4/2/2019 at 4:30 PM, the Facility Manager stated he was unaware the keypad did not work and would not unlock. Review of facility preventative maintenance paperwork revealed there was no documented evidence of egress doors or keypads being tested for functionality. 2012 NFPA 101: 19.2.2.2.5.1, 7.2.1.6.1 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedApril 29, 2019

1. Exit access door to first floor south building and exit door #11 keypads were repaired.
2. Keypads repaired on or before 6/4/19.
3. Education was provided to all staff on Egress Doors. Educational emphasis was placed on special needs locking arrangements.
4. The facility developed an audit tool to monitor compliance for egress door requirements related to special needs locking arrangements. The Facilities Manager or designee will audit all egress door keypads monthly for proper functioning. Audit findings will be reported to the Quality Assurance/Process Improvement Committee monthly for three months for evaluation and follow-up. At the end of the three-month period the committee will evaluate the need for additional monitoring or other corrective action. Ad Hoc meetings will be convened as needed.

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

REGULATION: Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: April 4, 2019
Corrected date: June 3, 2019

Citation Details

Based on record review and interview during the Life Safety Code survey, the facility did not ensure the generator testing was maintained. Specifically, 3 of 3 generators (North building, South building, West building) were not exercised once every 36 months for 4 continuous hours, as required. Findings include: Review of the facility's monthly load tests for 3 of 3 generators revealed there was no documented evidence of a 36 month, 4 hour exercise being performed on any of the generators. When interviewed on 4/4/2019 at 11:45 AM, the Facility Manager stated he was not aware of a 36 month, 4 hour continuous exercise being done for any of the generators in the 2 years he had been in his position. 2012 NFPA 99: 6.4.4.1.1.3 2010 NFPA 110 10 NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedApril 29, 2019

1. North, South, and West Building generators were exercised for 4 continuous hours.
2. Generator exercises will be complete on or by 6/4/19.
3. Education was provided to all maintenance staff regarding generators. Educational emphasis was placed on need for four-hour continuous generator testing every three years. Service contract updated to reflect need for specific testing.
4. The facility developed an audit tool to monitor compliance with generator testing. The Facilities Manager or designee will review Generator Service Contract annually to ensure requirement for four-hour testing is completed every 36 months. Audit findings will be reported to the Quality Assurance Committee quarterly for six months for evaluation and follow-up. At the end of the six-month period the committee will evaluate the need for additional monitoring or other corrective action. Ad Hoc meetings will be convened as needed.

K307 NFPA 101:EMERGENCY LIGHTING

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 4, 2019
Corrected date: June 3, 2019

Citation Details

Based on observation, record review, and interview during the Life Safety Code survey, the facility did not maintain emergency lighting for 2 of 3 generator rooms (North and South building generator rooms) and did not maintain documented monthly or annual testing of emergency lighting for 3 of 3 generator rooms, as required. Specifically, the North building generator room did not contain a battery-powered emergency lighting, the South generator room contained a non-functional battery-powered emergency light, and there was no documented evidence of monthly or annual testing for battery-powered emergency lighting in all 3 generator rooms. Findings include: 1) When observed on 4/1/2019 at 2:00 PM, there was no battery-powered emergency lighting within the North building generator room. When interviewed on 4/1/2019 at 2:00 PM, the Facility Manager stated he was unaware there was no emergency light in the North generator room. 2) When observed on 4/2/2019 at 2:30 PM, the battery-powered emergency light within the South building generator room was not operational when tested . When interviewed on 4/2/2019 at 2:30 PM, the Facility Manager stated he was unaware the emergency light was not working in the South generator room. Review of facility preventative maintenance inspection documentation on 4/4/2019 revealed there was no documented evidence of battery-powered emergency lighting being tested monthly or annually, as required. When interviewed on 4/4/2019 at 10:35 AM, the Facility Manager confirmed there was no documented testing for battery-powered emergency lighting. 2012 NFPA 101: 19.2.9.1, 7.9 2010 NFPA 110: 7.3.1 10NYCRR 415.29(a)(1&2), 711.2(a)(1)

Plan of Correction: ApprovedApril 29, 2019

1. A battery-powered emergency light was installed in the North building generator room and the battery-powered emergency light in the South building generator room was repaired.
2. Battery-powered emergency lights were installed and operational on or before 6/4/19.
3. Education was provided to all maintenance staff regarding emergency lighting. Educational emphasis was placed on battery-powered emergency lighting in generator rooms.
4. The facility developed an audit tool to monitor compliance with emergency lighting requirements related to generator rooms. The Facilities Manager or designee will audit all battery-powered emergency lights in generator rooms monthly for proper functioning. Audit findings will be reported to the Quality Assurance/Process Improvement Committee monthly for three months for evaluation and follow-up. At the end of the three-month period the committee will evaluate the need for additional monitoring or other corrective action. Ad Hoc meetings will be convened as needed.

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 4, 2019
Corrected date: June 3, 2019

Citation Details

Based on record review and interview during the Life Safety Code survey, the facility's fire alarm system was not inspected in accordance with the requirements of National Fire Protection Association (NFPA) 72. Specifically, 28 initiating devices were not inspected annually, and no semi-annual visual inspection was performed on all initiating devices, as required, for (YEAR). Findings include: Review on 4/4/2019 of the facility's annual fire alarm system inspection report, dated 10/29/18, it documented 18 smoke detectors, 4 heat detectors, 1 duct detector, and 4 smoke hatches were not inspected/tested annually, as required. The not inspected comments section included:Smoke detectors on the not inspected list are for no sensitivity performed. This was due to the location. Elevator shaft or above ceiling or over a patient bed. Duct detectors were not sensitivity tested . There was no documented evidence of the required semi-annual visual inspection of all initiating devices. When interviewed on 4/4/2019 at 12:00 PM, the Facility Manager stated he was unaware of the requirement for the semi-annual visual inspection and did not know that all initiating devices were not inspected/tested at the time of vendor inspection. He was not told there were smoke detectors that were not inspected. 2012 NFPA 101: 19.3.4.1, 9.6.1.5 2010 NFPA 72: 14.1, 14.3.1 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedApril 29, 2019

1. Simplex/Grinnell was contacted to visit facility to inspect the 28 initiating devices. All initiating devices were visually inspected.
2. The 28 initiating devices were inspected by SimplexGrinnell and all initiating devices were visually inspected on or by 6/4/19.
3. Education was provided to all maintenance staff regarding fire alarm testing. Educational emphasis was placed on the need for all initiating devices to be inspected annually and visually inspected semi-annually.
4. The facility developed an audit tool to monitor compliance with fire alarm testing related to initiating device inspections. The Facilities Manager or designee will audit two floors per month for visual inspection of all initiating devices. Audit findings will be reported to the Quality Assurance/Process Improvement Committee monthly for three months for evaluation and follow-up. At the end of the three-month period the committee will evaluate the need for additional monitoring or other corrective action. Ad Hoc meetings will be convened as needed.

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 4, 2019
Corrected date: June 3, 2019

Citation Details

Based on observations and interview during the Life Safety Code survey, the facility did not ensure the building was protected throughout by an approved automatic sprinkler system for 3 of 7 stairwells and 1 isolated area (North building center stairwell, North building west stairwell, South building A-side stairwell, and West building boiler room). National Fire Protection Association (NFPA) 13 - Standard for Installation of Sprinkler Systems 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, there was no sprinkler head installed at the bottom of the South building A-side stairwell at the first floor landing and all other areas listed contained both quick response and standard response sprinkler heads. Findings include: Missing sprinkler: When observed on 4/2/2019 at 2:18 PM, there was no sprinkler head installed at the bottom (1st floor landing) of the South building A-side stairwell. Mixed sprinkler heads: 1. When observed on 4/1/2019 at 12:10 AM, there were 2 quick response sprinkler heads and 2 standard response sprinkler heads located within the North building west stairwell. 2. When observed on 4/1/2019 at 1:42 PM, there were 2 quick response sprinkler heads and 1 standard response sprinkler head located within the North building center stairwell. 3. When observed on 4/2/2019 at 4:00 PM, there were 3 quick response sprinkler heads and 12 standard response sprinkler heads located within the West building boiler room. When interviewed on 4/1/2019 at 1:42 PM, the Facility Manager stated he was unaware there was a code requirement concerning mixed sprinkler heads. He was unaware there was any missing sprinkler heads in the building. NFPA 101: 19.3.5.1, 9.7.1.1 2010 NFPA 13: 8.3.3.2 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedApril 29, 2019

1. South building A-side (1st floor landing) stairwell sprinkler was installed. Standard sprinkler heads in North building west and center stairwells and in the West Wing boiler room were changed to quick response sprinkler heads.
2. South building A-side (1st floor landing) stairwell sprinkler installed on or before 6/4/19. Standard sprinkler heads were replaced by quick response sprinkler heads on or before 6/4/19.
3. Education was provided to all maintenance staff regarding Sprinkler System ? Installation. Educational emphasis was placed on where quick response sprinklers are installed, all sprinklers within a compartment shall be quick response.
4. The facility developed an audit tool to monitor compliance with sprinkler head installation. The Facilities Manager or designee will audit two floors each month to check for mixed sprinkler heads. Audit findings will be reported to the Quality Assurance/Process Improvement Committee monthly for three months for evaluation and follow-up. At the end of the three-month period the committee will evaluate the need for additional monitoring or other corrective action. Ad Hoc meetings will be convened as needed.

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 minimal harm
Citation date: April 4, 2019
Corrected date: June 3, 2019

Citation Details

Based on record review and interview during the Life Safety Code 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 3 of 3 building sprinkler systems (North building, South building, and West building). Specifically, there was no documented evidence of sprinkler system gauges being replaced every 5 years or an internal obstruction test being conducted every 5 years. Findings include: Review on 4/4/2019 of the facility's sprinkler inspection reports revealed there was no documented evidence that the gauges were replaced for 3 of 3 building sprinkler systems (North building, South building, and West building) every 5 years of an internal obstruction test was conducted every 5 years, as required. When interviewed on 4/4/2019 at 11:30 AM, the Facility Manager stated he was unaware if the sprinkler system gauges were replaced nor if there was an internal obstruction test performed on any of the sprinkler systems. 2012 NFPA 101: 19.3.5.1, 9.7.5 2011 NFPA 25 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedApril 29, 2019

1. Evans Mechanical was contracted to perform 5-year sprinkler internal obstruction testing and replace sprinkler gauges for North, South, and West buildings.
2. Gauges replaced and dated, and internal sprinkler obstruction testing completed on or before 6/4/19.
3. Education was provided to all maintenance staff regarding sprinkler system testing. Educational emphasis was placed on need to replaced sprinkler gauges every 5 years and need to perform internal sprinkler obstruction testing every 5 years.
4. The facility developed an audit tool to monitor compliance with sprinkler system maintenance and testing. The Facilities Manager or designee will inspect gauges quarterly to ensure proper functioning. Audit findings will be reported to the Quality Assurance Committee monthly for six months for evaluation and follow-up. At the end of the six-month period the committee will evaluate the need for additional monitoring or other corrective action. Ad Hoc meetings will be convened as needed.

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 4, 2019
Corrected date: June 3, 2019

Citation Details

Based on observations, record review, and interviews during the Life Safety Code Survey, the facility did not ensure 2 of 12 smoke barrier walls within the North building were properly maintained on resident-occupied units. Specifically, there were unsealed openings above the suspended ceiling were the wall was not continuous from an outside wall to an outside wall or from a floor to a floor, as required. Findings include: 1) When observed on 4/3/2019 at 10:30 AM, the fire rated smoke barrier wall adjacent to resident room 232 did not extend from the outside wall to the outside wall or to the deck above, as required. This created approximately a 10 inch (in) by 6 foot (ft) long unsealed section of the wall. 2) When observed on 4/3/2019 at 10:50 AM, the fire rated smoke barrier wall adjacent to resident room 33 did not extend from the outside wall to the outside wall or to the deck above, as required. This created approximately a 3 ft by 8 ft long unsealed section of the wall. When interviewed on 4/3/2019 at 10:50 AM, the Facility Manager stated he was unsure of the reason the contractor did not finish the wall to the floor above. When interviewed on 4/4/2019 at 10:30 AM, the Facility Civil Engineer stated the wall was supposed to be constructed as a 1-hour fire rated barrier wall. Review of the North building as built drawings revealed the smoke barrier walls were designed to be constructed of 1-hour fire rated material that extended from outside wall to outside wall and from floor to floor. 2012 NFPA 101: 19.3.7.3, 8.5.2.2 10 NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedApril 29, 2019

1. Smoke barrier walls adjacent to resident room 232 and room 33 were closed off from outside wall to outside wall and to the deck above as required.
2. Smoke barrier walls were closed off on or before 6/4/19
3. Education was provided to all maintenance staff regarding smoke barrier walls. Education emphasis was placed on walls to extend from outside wall to outside wall and to the deck above.
4. The facility developed an audit tool to monitor compliance with smoke barrier walls. The Facilities Manager or designee will audit all smoke barrier walls after construction to ensure they extend from outside wall to outside wall and to the deck above monthly. Audit findings will be reported to the Quality Assurance Committee monthly for three months for evaluation and follow-up. At the end of the three-month period the committee will evaluate the need for additional monitoring or other corrective action. Ad Hoc meetings will be convened as needed.