Waterview Nursing Care Center
November 23, 2016 Certification Survey

Standard Health Citations

FF09 483.20(d), 483.20(k)(1):DEVELOP COMPREHENSIVE CARE PLANS

REGULATION: A facility must use the results of the assessment to develop, review and revise the resident's comprehensive plan of care. The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.25; and any services that would otherwise be required under §483.25 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(b)(4).

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 23, 2016
Corrected date: December 23, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview during the recertification survey the facility did not develop a Comprehensive Care Plan (CCP) with goals and interventions specific to the medical needs of the resident. This was evident for two of thirty Stage 2 sampled residents. Specifically, 1) Resident #65 did not have a CCP developed following a head injury from a fall. 2) Resident #86 did not have a CCP for the [DIAGNOSES REDACTED]. The findings are: 1) Resident #65 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) Score of 9, indicating moderately impaired cognition. The MDS documented that the resident required staff assistance and supervision in all activities of daily living. The Nursing Progress note dated 6/27/16 at 8:44 PM documented that the resident was found lying on the floor at 7:10 PM. The Nursing Progress note further documented that the resident was sent to the hospital emergency room (ER) with complaints of a headache. A Nursing Progress note documented on 6/28/16 at 12:20 PM that the resident had returned from the ER and that the Computerized Axial Tomography (CAT) Scan of the head was suspicious for hemorrhage. The CCP for Falls dated 6/27/16 documented that the resident was observed lying on the floor in the hallway by her room. There was no further documentation regarding the results of the fall and the interventions required status [REDACTED]. The Assistant Director of Nursing (ADNS)/Registered Nurse (RN) was interviewed on 11/22/2016 at 2:51 PM. The ADNS stated that Resident #65 had a Pain Scale and Neurological (Neuro) checks done on readmission. The ADNS stated that the Unit Nurse or RN Supervisor should have documented the information on the CCP. 2) Resident #86 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident has a Brief Interview for Mental Status (BIMS) Score of 6, indicating that the resident had severely impaired cognition. The MDS documented that the resident had a Mood Score of 6 which indicated Mild Depression. In addition, the MDS documented that the resident required staff assistance in all Activities of Daily Living. The physician's orders [REDACTED]. The MDS assessment dated [DATE] documented the [DIAGNOSES REDACTED]. There was no CCP developed for the resident's [DIAGNOSES REDACTED]. The MDS Coordinator/RN was interviewed on 11/22/2016 at 2:13 PM. The RN stated that the [DIAGNOSES REDACTED].#86 had not been documented on the MDS. The RN stated that the CCP's are developed from the physician's orders [REDACTED]. The RN/CCP Coordinator was interviewed on 11/22/2016 at 3:26 PM. The RN stated that the CCP for [MEDICAL CONDITION] was an oversight and should have been completed. 415.11(c)(1)

Plan of Correction: ApprovedDecember 13, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I: The facility respectfully states that resident # 65 no longer resides at the facility.
A Comprehensive Care Plan (CCP) was developed for Resident #86 for [MEDICAL CONDITION]. The CCP was reviewed and evaluated by the IDC Team.
The RN(s) responsible for CCP development and for interim resident needs care plan development received educational counseling for not developing the care plans in a timely manner.
II: The facility respectfully states that all residents were potentially affected.
The Director of Nursing Services / designee reviewed all resident care plans completed in the last quarter to assess if any residents did not have their medical needs addressed. Any identified issues were corrected.
III: The Director of Nursing Services / designee reviewed the Policy and Procedure (P&P) for Care Planning and found same to be compliant.
All RNs and IDC Team members were re-inservice on the P&P for Care Planning in particular the developing CCPs and interim needs care plans in a timely manner.
IV: The Director of Nursing Services /designee will conduct random audits of 4 residents weekly for 1 month and monthly thereafter for 5 months to ensure CCPs are being developed in a timely manner. Audits with negative findings will have immediate corrective actions taken.
Audit findings will be presented to the Quality Assurance Committee at least quarterly for review and revisions to the action plan, if warranted.
V: The Director of Nursing Services is responsible for ensuring compliance.

FF09 483.25(l):DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS

REGULATION: Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 23, 2016
Corrected date: December 23, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on electronic medical record (EMR) review and staff interviews during the recertification survey, the facility did not ensure that each resident's drug regimen was free from unnecessary medications for one of three residents reviewed for hospitalization in a total Stage two sample of 30 residents. Specifically, Resident #153 was administered an antipsychotic medication, [MEDICATION NAME] 50 milligram (mg) at hour of sleep (hs), without any documented evidence of non- pharmacological interventions being attempted prior to administration. The finding is: Resident # 153 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The resident is Spanish speaking. The Minimum Data Set (MDS) assessment dated [DATE] documented in the Brief Interview for Mental Status (BIMS) section that the resident had a BIMS Score of 2 indicating that the resident had severely impaired cognition. A nursing progress note dated 6/10/16 at 8:25 PM documented that the resident was noted with confusion, very combative and aggressive attempting to get out of bed. The Physician was notified and an order for [REDACTED]. A Medication Order Form dated 6/10/16 documented an order for [REDACTED]. A review of the Medication Administration Record [REDACTED]. On 11/23/16 at 1:30 PM the Psychiatrist was interviewed. The Psychiatrist stated that on 6/1/16 he saw the resident in the presence of an translator. The Psychiatrist stated that before the [MEDICATION NAME] was prescribed by the physician there should have been documented evidence that non-pharmacological interventions had been attempted. The Psychiatrist also stated that Unspecified Dementia without Behavioral Disturbance was an incorrect [DIAGNOSES REDACTED]. The Psychiatrist further stated that [MEDICATION NAME] (helps to decrease tremors and other symptoms of [MEDICAL CONDITION]) can cause [MEDICAL CONDITION]. On 11/23/16 at 1 :35 PM the attending Medical Doctor (MD) was interviewed. The MD stated that Unspecified Dementia without Behavioral Disturbance was the wrong [DIAGNOSES REDACTED]. The MD also stated that he would have ordered a follow up psychiatric consult but he wanted to wait a little longer. 415.12(l)(1)

Plan of Correction: ApprovedDecember 13, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I: The facility respectfully states that resident # 153 no longer resides at the facility
The charge nurse received educational counseling for not documenting non- pharmacological interventions attempted and for not contacting the RNS to assess Resident #153.
The Attending Physician received an educational counseling for failure to ascertain whether non- pharmacological interventions were attempted prior to initiating a [MEDICAL CONDITION] medication and documenting an incorrect diagnosis.
II: An audit was done on all [MEDICAL CONDITION] medications ordered in the last 90 days to ensure that all other residents prescribed with [MEDICAL CONDITION] medication had appropriate [DIAGNOSES REDACTED]. Any identified issues were corrected.
III: The Medical Director in conjunction with the DNS reviewed the facility Policy and Procedure (P&P) for Anti-psychotic medication administration and found same to be compliant.
All physicians, licensed nurses and IDC Team were re- inserviced on this P&P, in particular, the requirement of non-pharmacological interventions prior to the prescription of [MEDICAL CONDITION] medication and ensuring all residents prescribed with [MEDICAL CONDITION] medication had appropriate diagnoses
IV: The Medical Director/ designee will conduct random audits of 4 residents weekly for 1 month and monthly thereafter for 5 months to ensure residents receiving antipsychotic medication are assessed for appropriate clinical indications, [DIAGNOSES REDACTED]. Audits with negative findings will have corrective actions taken.
Audit findings will be presented to the Quality Assurance Committee at least quarterly for review and revisions to the action plan, if warranted.
V: The Medical Director is responsible for ensuring compliance.

FF09 483.70(c)(2):ESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION

REGULATION: The facility must maintain all essential mechanical, electrical, and patient care equipment in safe operating condition.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 23, 2016
Corrected date: December 23, 2016

Citation Details

Based on observations, record review and staff interviews during the recertification survey, the facility did not ensure that all essential mechanical, electrical, and patient care equipment was maintained in safe operating condition. Specifically, during a review of the kitchen and food storage equipment on 11/18/16 at 10:15 AM, a walk-in refrigerator was found with an inoperable panic latch on the interior. The finding is: On initial tour on 11/18/16 at 10:15 AM, walk-in refrigerator #6 was observed to have a broken escape latch mechanism. The Food Service Director was interviewed on 11/18/16 at 10:15 AM. She stated that she has been aware of the broken mechanism for at least a week and had intended to refer it to the maintenance department for repair. On the last day of survey, 11/23/16, at 1:20 PM, refrigerator #6 was observed again. The latch was still inoperable on 11/23/16. The Food Service Director stated that she would refer the matter back to the maintenance department. The Food Service Director stated on 11/23/16 at 1:00 PM that she is responsible for the safe function of all of the equipment associated with the dietary department. 415.29(b)

Plan of Correction: ApprovedDecember 13, 2016

I: The panic latch on the walk-in refrigerator #6 was replaced.
II: An audit was done on all walk-in refrigerators and freezers to ensure the panic latching mechanisms were operational. Any panic latches found to be inoperable were repaired or replaced.
III: A Maintenance Log Book was issued for the kitchen which will be checked daily by the Maintenance Department
All dietary staff were in-serviced on reporting any malfunctioning equipment to the maintenance department.
IV: The Food Service Director/designee will conduct weekly audits of all dietary refrigerators for 1 month and monthly thereafter for 5 months to ensure they are in safe operating condition. Audits with negative findings will have corrective actions taken.
Audit findings will be presented to the Quality Assurance Committee at least quarterly for review and revisions to the action plan, if warranted.
V: The Food Service Director is responsible for ensuring compliance.

FF09 483.25(h):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 23, 2016
Corrected date: December 23, 2016

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not ensure that the resident environment remained as free of accident hazards as is possible on 2 of 5 nursing units. Specifically, disposable razors were found on the window sills in the resident shower rooms on the second and third floor nursing units; a bottle of hydrogen peroxide without a cap was found in the third floor resident shower room; a handrail in the third floor resident shower room was loose; two unattended mop basins were observed in the third floor tub room with containers of chemical cleaners attached to the basins with the door to the tub room fully open; the porter's closet door on the third floor was partially open and was unable to be locked even when the door was fully closed and there were chemical cleaners inside the closet. The findings are: On 11/18/2016 at 9:27 AM three unused disposable razors and an open bottle of hydrogen peroxide were observed on the window sill in the third floor shower room. In addition, a loose handrail was also observed in the same shower room. The razors and hydrogen peroxide were brought to the attention of the Licensed Practical Nurse (LPN) Charge Nurse who observed them and stated they should not be there. The LPN stated she would notify the Maintenance Department about the handrail. On 11/18/2016 at 9:30 AM the razors and hydrogen peroxide were observed by a CNA. She stated the razors were not used yet and disposed them into the sharps container that was in the shower room. In addition, the CNA removed the open bottle of hydrogen peroxide. On 11/18/2016 at 9:34 AM in the third floor tub room, two unattended mop bins were observed with Fusion(NAME)cleaner and Fusion Denim cleaner containers attached to them. The door to the tub room was fully open and an ambulatory resident was observed standing outside the room. The mop bins and cleaners were brought to the attention of the LPN Charge Nurse. She stated she would notify the housekeeper. On 11/18/2016 at 9:46 AM the third floor porter's closet door was open, and when it was fully closed the door did not lock and could be re-opened. Inside the closet were containers of bleach, Fusion(NAME)cleaner, and Fusion Rose cleaner. The LPN Charge Nurse observed the same and stated she would let the Maintenance Department know. On 11/18/2016 at 10:02 AM three unused disposable razors were observed on the window sill in the second floor shower room. The razors were brought to the attention of the Registered Nurse (RN) Unit Supervisor. She removed the razors and stated they should not be there. On 11/18/2016 at 2:29 PM the Material Safety Data Sheet (MSDS) book was received from the Director of Maintenance and Housekeeping. Sheets were found in the book for the denim and violet cleaners; however, there were no sheets for bleach and the rose cleaner. On 11/21/2016 at 8:33 AM the Director of Maintenance and Housekeeping was interviewed. He stated that the MSDS book that he provided on 11/18/2016 was from the 1 North nursing unit. He provided the MSDS sheets for the bleach and rose cleaner. He said he had them but they were not in the MSDS book. The MSDS sheets were reviewed and the following hazards were identified: -Fusion Rose--May cause eye irritation and may be irritating to mouth, throat, and gastrointestinal system. -Fusion Denim--May cause eye and skin irritation and may be irritating to mouth, throat, and gastrointestinal system. -Fusion Violet--May cause eye irritation and may be irritating to mouth, throat, and gastrointestinal system. -Bleach--May cause serious eye damage/irritation and skin corrosion/irritation. On 11/21/2016 at 10:00 AM the third floor porter's closet was observed open. The door did not lock when the door was closed. This was the same unlocked door that was observed on 11/18/16. On 11/23/2016 at 8:03 AM the Director of Nursing Services (DON) was interviewed. She stated that the CNAs are supposed to get one razor at a time from the storeroom and deposit the razor in the sharps container when done. She stated that the CNAs should not be storing disposable razors in the shower rooms. She added that hydrogen peroxide should not be in the shower room. On 11/23/2016 at 10:04 AM the Director of Maintenance and Housekeeping was interviewed. He stated that the porter's closet should be locked and hazardous chemicals should not be accessible. He stated that a mop basin should not be left unattended with chemical cleaners. Regarding the loose handrail in the third floor shower room, the Director of Maintenance and Housekeeping stated that maintenance rounds are done on a daily basis. He also said that if the nurses and CNAs on each unit identify problems, that they are supposed to enter the problem in the maintenance log on each unit. 415.12(h)(1)

Plan of Correction: ApprovedDecember 13, 2016

I: The disposable razors found on the window sills in the second and third floor shower rooms were removed.
The open bottle of hydrogen peroxide in the third floor shower room was removed.
The loose hand rail in the third floor shower room was repaired.
The unattended mop basins found in the third floor tub room were removed.
The self-locking knob on the third floor porters closet was repaired.
II: A visual audit was done on all shower rooms, tub rooms and porter closest to ensure the resident environment was as free from of accident hazards as possible. Any identified issues were corrected.
III: Nursing, Housekeeping and Maintenance Department staff were in-serviced on keeping resident environment was as free from of accident hazards as possible, in particular, the proper storage of disposable razors and hazardous chemicals and the reporting of potential hazards.
IV: The Director of Environmental Services /designee will conduct rounds on a daily basis for one month and monthly thereafter for 5 months to ensure the proper storage of disposable razors and hazardous chemicals. Audits with negative findings will have corrective actions taken.
Audit findings will be presented to the Quality Assurance Committee at least quarterly for review and revisions to the action plan, if warranted.
V: The Director of Environmental Services is responsible for ensuring compliance.

FF09 483.25(i):MAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE

REGULATION: Based on a resident's comprehensive assessment, the facility must ensure that a resident - (1) Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible; and (2) Receives a therapeutic diet when there is a nutritional problem.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 23, 2016
Corrected date: December 23, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview during the recertification survey, the facility did not ensure that acceptable parameters of nutritional status were maintained for one of four residents reviewed for Nutrition in a total sample of thirty Stage 2 residents. Specifically, Resident #130 had a significant weight loss on 10/1/16 with no change in their plan of care to prevent further weight loss until 11/21/16 when their nutritional supplement was increased. The finding is: Resident #130 has [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident was understood and could understand and had a Brief Interview for Mental Status score of 6 which indicated that the resident had severely impaired cognitive skills for daily decision making. The resident required supervision and setup help only for eating. The MDS also documented that the resident had a weight loss of 5% or more in the last month or a loss of 10% or more in the last 6 months and was not on a physician-prescribed weight loss-regimen. The resident's weight was documented as 131 pounds (lbs) with a height of 73 inches (6 feet 1 inch). The resident's weights in the EMR (electronic medical record) for the past 6 months were documented as follows: 5/03/16: 145.6 lbs 6/14/16: 142 lbs 70/8/16: 145.6 lbs 8/10/16: 146 lbs 9/09/16: 143 lbs 10/01/16: 136 lbs 11/01/16: 130.4 lbs These weights reflected a 12% significant weight loss in 6 months from (MONTH) to November, a 12% significant weight loss in 3 months from (MONTH) to November, and a 5% significant weight loss in 1 month from (MONTH) to October. The resident's Nutrition Full assessment dated [DATE] documented that the resident received a NAS (No Added Salt) diet with a Chopped/Thin Liquids diet consistency. The resident was also receiving Ensure Plus (a liquid nutritional supplement) once per day. The resident's BMI was documented as 19.3. There were no further Nutritional Assessments found in the resident's medical record. The resident's Nutrition and Nursing Notes were reviewed on 11/22/16 at 1:30 PM and revealed no documented evidence that the Registered Dietitian (RD) or Nursing was aware of the resident's significant weight loss. The resident's Physician Monthly Note dated 10/26/16, and written by the Nurse Practitioner, revealed under the History of Present Illness section that the resident was noted with progressive weight loss, present weight 136 lbs with a BMI (Body Mass Index) of 17.1. Per staff, the resident eats 50-75% of meals and receives one Ensure Plus (a liquid nutritional supplement) daily. The Treatment Plan section documented that the resident had moderate protein-calorie malnutrition as evidenced by muscle wasting, subcutaneous fat loss, and progressive weight loss. The resident's present weight was 136 with a BMI of 17.1. The Goal was for the resident to maintain adequate nutritional status as evidenced by maintaining weight within 145-158 lbs, no signs or symptoms of malnutrition, and consuming at least 75% of at least three meals daily through the review date. The Plan was to continue the current P(NAME) (plan of care) and supplements. The physician's orders [REDACTED]. The RD was interviewed on 11/22/16 at 3:15 PM and stated that Nursing should contact her if there is a change in a resident's weight plus or minus 5 lbs and then reweigh the resident. The RD stated that she did not know why she did not write a note acknowledging the resident's significant weight loss. The RD further stated that if a resident shows a significant weight loss she would usually write a Nutrition Progress Note, speak to the resident and update their food preferences, increase their supplements, and do a 3-Day Calorie Count. The Registered Nurse (RN) West Unit Manager was interviewed on 11/23/16 at 9:25 AM and stated that all monthly weights must be completed by the 7th of every month and then submitted to the RD. The RD then goes through the weights to see which residents need to be reweighed. The RN state that residents who have gained or lost 5 lbs in one month are reweighed. The RN stated that she believed that the RD tells the Charge Nurse on every unit who needs to be reweighed. The RN also acknowledged that there were no Nursing Progress Notes which addressed the resident's significant weight loss. The Licensed Practical Nurse (LPN) Charge Nurse who was on the West Unit at the beginning of (MONTH) was interviewed on 11/23/16 at 10:20 AM and stated that all monthly weights are done by the 5th of every month and then the RN Unit Manager compares it to the previous month's weight to see if there are any weight changes plus or minus 5 pounds. The LPN stated that she then gets a revised sheet which tells her which resident has to be reweighed. The LPN stated that she did not recall any significant weight loss for the resident. The Director of Nursing (DON) was interviewed on 11/23/16 at 10:35 AM and stated that the LPN Charge Nurse ensures that monthly weights are done by the 7th of every month. When the weights are complete, the LPN Charge Nurse then gives the weights to the RN Unit Manager who gives it to the RD. The DON stated that in the past, Nursing had reviewed the weights to see which resident needed a reweigh, but now the current RD reviews the weights and tells the RN Unit Manager who has to be reweighed. The RD will have the reweigh performed by Nursing that day or the next day. If a resident is found to have a significant weight loss, the RD will make a recommendation for the resident to be placed on weekly weights or a supplement. The Nurse Practitioner was attempted to be contacted via telephone on 11/23/16 at 12:15 PM and was unable to be reached. The resident's Primary Physician was interviewed on 11/23/16 at 1:30 PM and stated that the resident's [MEDICATION NAME] (a [MEDICAL CONDITION] medication) was discontinued which may have caused his loss of appetite. The Physician stated that he remembered discussing with the NP to start the resident on weekly weights and a 3-Day Calorie Count, however she did not order either. The Physician stated that the NP did not document their conversation and she should have. The Primary Physician stated that he would now start the resident on weekly weights and a 3-Day Calorie Count. The physician's orders [REDACTED]. The facility's Body Mass Index Policy and Procedure revised 2/16 documented that a BMI of 19 or less may indicate nutritional depletion and that normal BMI is 18.6-24.9. The facility's Weight Change Policy and Procedure revised 7/16 revealed that whenever an unintended change in weight is identified, the RD must have the resident reweighed immediately. If the change is confirmed, the attending (Primary) Physician must be notified within 24 hours and the unintended weight change must be discussed at a conference (formal or informal team) and a full MDS initiated if indicated. 415.12(i)(1)

Plan of Correction: ApprovedDecember 13, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I: The Registered Dietitian (RD) reassessed the resident# 130 and their nutritional needs based on completed calorie count, current weight and food preferences.
The Attending Physician reassessed resident # 130 and ordered RD recommendations and labs to assess nutritional status.
The RD?s recommendation were ordered by the Attending Physician
The RD received disciplinary counseling for failure to observe and act on resident # 130 significant weight loss in accordance with the facilities Policy and Procedure (P&P).
The Unit nurse and RN received disciplinary counseling for failure to document, report and follow up on resident # 130 significant weight loss.
The Attending Physician received disciplinary counseling for failure to follow up on and document a significant weight loss for Resident #130.
The facility established a Weight Loss Committee and held an Ad Hoc meeting.
II: All resident weights were reviewed by the RD in conjunction with the Facility Weight Committee to ascertain if any other residents had experienced weight loss that was not reported and followed. Any identified issues were addressed.
III: The Director of Nursing Services in conjunction with the RD and Medical Director reviewed the Policy and Procedure (P&P) for Monitoring Resident weights and found same to be compliant.
All dietitians, licensed nurses, physicians and NPs were re-inserviced on this P&P, in particular, obtaining accurate monthly weights, identifying weight changes assessing nutritional needs obtaining physician orders [REDACTED].
IV: The Director of Nursing Services /designee will conduct random audits of 4 residents weekly for 1 month and monthly thereafter for 5 months to ensure resident weight loss and nutritional issues are identified and addressed in a timely manner. Audits with negative findings will have corrective actions taken.
Audit findings will be presented to the Quality Assurance Committee at least quarterly for review and revisions to the action plan, if warranted.
V: The Director of Nursing Services is responsible for ensuring compliance.

FF09 483.70(h)(1):PROCEDURES TO ENSURE WATER AVAILABILITY

REGULATION: The facility must establish procedures to ensure that water is available to essential areas when there is a loss of normal water supply.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 23, 2016
Corrected date: December 23, 2016

Citation Details

Based on observations, record review, and staff interviews during the recertification survey, the facility did not ensure that procedures were established to ensure that water was available to essential areas when there is a loss of normal water supply. Specifically, during a review of the emergency water supply on 11/18/16, 4 five gallon water bottles were identified as the emergency water supply for the facility with a census of 162 residents. The finding is: On initial tour on 11/18/16 at 10:00 AM, 4 five gallon containers of water were observed to be stored in the basement and identified as the emergency water supply by the Food Service Director (FSD). The FSD was interviewed on 11/18/16 at 10:00 AM and stated that the observed water supply was their emergency supply and that the facility had an agreement with an offsite provider for delivery of additional water in the event of an emergency. A total of 20 gallons was observed for a census of 162 residents, amounting to 0.123 gallons of water per resident for emergency. The Policy & Procedure for emergency water supply, dated 11/2015 was reviewed. The policy documented that the facility will keep on hand a minimum of a one day supply of water. The 20 gallon water supply was not adequate for the 162 residents present on that first day of survey in the event of an emergency. 415.29(f)(1-7)

Plan of Correction: ApprovedDecember 16, 2016

I: In order to stock the emergency water supply with a sufficient amount of water, additional water was purchased. The facility now stocks 300 gallons of emergency water.
II: The facility respectfully states that all residents were potentially affected.
The emergency water supply was stocked with a sufficient amount of water. The facility now stocks 300 gallons of emergency water.

III: The Food Service Director in conjunction with Administrator the reviewed the facility Policy and Procedure (P&P) for Emergency Water Supply and found same to be compliant.
The dietary staff were in-serviced on the facility?s P&P on Emergency Water Supply.
VI: The Food Service Director/designee will conduct weekly audits of the emergency water supply for 1 month and monthly thereafter for 5 months to ensure there is a sufficient amount of water in stock. Audits with negative findings will have corrective actions taken.
Audit findings will be presented to the Quality Assurance Committee at least quarterly for review and revisions to the action plan, if warranted.
V: The Food Service Director is responsible for ensuring compliance.

FF09 483.15(e)(1):REASONABLE ACCOMMODATION OF NEEDS/PREFERENCES

REGULATION: A resident has the right to reside and receive services in the facility with reasonable accommodations of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 23, 2016
Corrected date: December 23, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff and resident interviews during the recertification survey, the facility did not ensure all residents received services with reasonable accommodations of individual needs. This was identified for one of forty census sampled residents. Specifically, Resident #67 was observed in bed with the call bell wrapped around the headboard of the bed and out of reach of the resident. The finding is: Resident #67 has [DIAGNOSES REDACTED]. The 9/1/2016 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview of Mental Status (BIMS) score of 10, indicating the resident has moderate cognitive impairment. The MDS documented that the resident had no impairment to upper extremity range of motion. On 11/23/2016 at 10:15 AM Resident #67 was observed in bed. His call bell was behind his bed wrapped around the headboard and out of his reach. On 11/23/2016 at 10:20 AM the resident's call bell location was brought to the attention of the unit Registered Nurse (RN). The RN observed the call bell behind the resident's bed and out of the resident's reach. The RN stated the call bell should be within his reach. The RN placed the call bell on the bed on the resident's right side. The RN stated that the resident is able to use the call bell. On 11/23/2016 at 10:22 AM Resident #67's Certified Nursing Assistant (CNA) was interviewed. She stated the resident is able to use the call bell and did not know why it was behind his bed. 415.5(e)(1)

Plan of Correction: ApprovedDecember 13, 2016

I: The residents call bell was placed on the right side on Resident # 67?s bed.
The Nurse and Certified Nursing Assistant (CNA) who were assigned to the resident on 11/23/16 received educational counselling for failing to follow facility policy and procedure regarding Call (NAME)s.
II: The facility respectfully states that all residents were potentially affected.
A visual audit was done on all residents to ensure proper call bell placement. Any identified issues were corrected.
III: Nursing, Housekeeping, Maintenance, Therapy and Recreation Department Staff were re-inserviced by the Director of Nursing Services on Resident Rights, in particular, to ensure that call bells are in reach of the resident.
IV: The Director of Nursing Services /designee will conduct random audits of 4 residents weekly for 1 month and monthly thereafter for 5 months to ensure the proper call bell placement. Audits with negative findings will have corrective actions taken.
Audit findings will be presented to the Quality Assurance Committee at least quarterly for review and revisions to the action plan, if warranted.
V: The Director of Nursing Services is responsible for ensuring compliance.

FF09 483.75(l)(1):RES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE

REGULATION: The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized. The clinical record must contain sufficient information to identify the resident; a record of the resident's assessments; the plan of care and services provided; the results of any preadmission screening conducted by the State; and progress notes.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: November 23, 2016
Corrected date: December 23, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview during the recertification survey, the facility did not maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized for 1 of 6 residents observed during Medication Administration Pass (med pass). Specifically, during the med pass observation for Resident #165 the Licensed Practical Nurse (LPN) Medication Nurse was observed documenting a blood sugar fingerstick value and the insulin coverage that was provided earlier that morning; however, the documentation inaccurately reflected the actual time the fingerstick and insulin coverage was done. The finding is: Resident #165 has [DIAGNOSES REDACTED]. The 10/13/2016 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 6, indicating the resident has severe cognitive impairment. A physician's orders [REDACTED]. The sliding scale requires 2 units of Humalog be administered if the blood sugar is between 151-200. On 11/22/2016 at 9:01 AM during medication administration observation for Resident #165, the LPN Medication Nurse was observed glancing at the glucometer and stating that Resident #65's blood sugar at 7:30 AM was 163. The glucometer did not indicate the resident's name. The LPN stated that she remembered it was 163 because only a few residents get fingersticks. She stated that she gave 2 units of insulin per the sliding scale order earlier in the morning. She stated that she usually documents at the time of checking the fingerstick and giving the insulin but was unable to earlier in the morning because she was too busy at 7:30 AM. At 9:01 AM, the LPN was observed entering the fingerstick value and administration of the insulin into the computer that was provided earlier in the morning. A printout of Resident #165's glucose log revealed the time the fingerstick was checked and the corresponding insulin coverage was always 7:30 AM, 11:30 AM, and 4:30 PM on a daily basis, which corresponded with the physician's orders [REDACTED]. On 11/22/2016 2 units of insulin were documented as being given at 7:30 AM for a blood sugar of 163; however, the documentation occurred at 9:01 AM. On 11/22/2016 at 11:20 AM the Assistant Director of Nursing Services (ADON) was interviewed. She stated that the computer system does not show the actual time of administration or the actual time when the nurse documents the administration. She stated only the ordered time is indicated (i.e. 7:30 AM). She stated that there is a window for administration of 1 hour before and 1 hour after the ordered time, but that the exact time of administration should be documented. 415.22(a)(1-4)

Plan of Correction: ApprovedDecember 13, 2016

I: The Nurse received educational counseling by the Director of Nursing Services on proper procedure for signing off medications and treatments at the time of administration.
II: The facility respectfully states that all residents were potentially affected.
The Director of Nursing Services in conjunction with the Medical Director reviewed the facility Policy and Procedure (P&P) for Medication and Treatment Administration and found same to be compliant.
Licensed nursing staff were re-inserviced on these P&P, in particular, on the proper procedure for signing off medications and treatments at the time of administration
III: The Director of Nursing Services/designee will do random medication administration observations and review Medication Administration Records to ensure medication and treatment administration are documented at the time of administration. Follow up actions will be taken immediately as necessary.
IV: The Director of Nursing Services/designee will conduct this audit weekly for 1 month and monthly thereafter for 5 months. Audits with negative findings will have corrective actions taken.
Audit findings will be presented to the Quality Assurance Committee at least quarterly for review and revisions to the action plan, if warranted.
V: The Director of Nursing Services is responsible for ensuring compliance.

FF09 483.20(k)(3)(ii):SERVICES BY QUALIFIED PERSONS/PER CARE PLAN

REGULATION: The services provided or arranged by the facility must be provided by qualified persons in accordance with each resident's written plan of care.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 23, 2016
Corrected date: December 23, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Electronic Record Review (EMR) and staff interviews during the recertification survey, the facility did not administer two medications according to Physician order [REDACTED]. Specifically, 1) Resident #109 had a physician's orders [REDACTED]. 2) Resident #153 was to receive [MEDICATION NAME] lid scrub at hour of sleep (hs) for 30 days, but only received the lid scrub on nine of the 25 evenings the resident was in the facility. The findings are: 1) Resident #109 has [DIAGNOSES REDACTED]. The resident was readmitted from the hospital on [DATE]. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented that the resident was understood and could understand. The resident had a Brief Interview for Mental Status (BIMS) score of 12 which indicated that the resident had moderately impaired cognitive skills for daily decision making. The MDS also documented that the resident received [MEDICAL TREATMENT]. The physician's orders [REDACTED]. Special Instructions: give with meals. Diagnosis: [REDACTED]. Review of the Medication Administration Records (MARs) dated (MONTH) (YEAR) and (MONTH) (YEAR) revealed that the resident was being administered the [MEDICATION NAME] tablets at 4:30 AM, 7:30 AM, and 8:00 PM. The Registered Nurse (RN) West Unit Manager was interviewed on 11/23/16 at 9:50 AM and stated that the resident's [MEDICATION NAME] medication was not being administered at the times that the Physician wanted the medication to be given. The RN stated that the times should have been 7:00 or 8:00 AM, 12:00 PM, and 5:00 PM. The RN stated that she would call the Physician and have the administration times changed right away. The ADON was interviewed on 11/23/16 at 10:00 AM and stated that those administration times were definitely an error and that the administration times should have been entered into the computer as 9:00 AM, 1:00 PM, and 5:00 PM. The ADON stated that the Nurses giving the medication should have picked up on the error, especially the 4:30 AM time because no resident in the facility gets medication at 4:30 AM. The 11:00 PM - 7:00 AM Licensed Practical Nurse (LPN) Medication Nurse was attempted to be contacted via telephone on 11/23/16 at 12:20 PM and was unable to be reached.
2) Resident # 153 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented in the Brief Interview for Mental Status (BIMS) section that the resident had a BIMS Score of 2 indicating that the resident had severely impaired cognition. On 6/2/16 the resident was seen by the Ophthalmologist. The Ophthalmologist documented that the resident had Blepharitis (an inflammation of the eyelid that affects the eyelashes or tear production) of both eyes. The Ophthalmologist recommended that the resident receive [MEDICATION NAME] lid scrub at hour of sleep (HS) for 30 days. Additionally, the resident was to receive [MEDICATION NAME] ophthalmic ointment 500unit/gm to both eyes for 2 weeks. A review of the Medication Administration Record [REDACTED]. There was no documented evidence on the MAR for nine of the dates that the [MEDICATION NAME] lid scrub had been administered. There was no documented evidence in the EMR as to why the [MEDICATION NAME] had not been provided to the resident. On 11/23/16 at 10:00 AM the Assistant Director of Nursing (ADNS) was interviewed. The ADNS stated that the Licensed Practical Nurse (LPN) should have documented in the EMR the reason why the [MEDICATION NAME] scrub was not provided. The LPN responsible for the nine omissions of the [MEDICATION NAME] lid scrub was unavailable for interview. 415.11(c)(3)(ii)

Plan of Correction: ApprovedDecember 13, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I: The Attending Physician reassessed Resident # 109 and no adverse event was noted.
The Attending Physician revised the medication order for Resident # 109 to be in conjunction with facility mealtimes.
The Charge Nurse updated MAR in accordance with the Attending Physician order.
The facility respectfully states that resident # 153 no longer resides at the facility.
The RN responsible for entering the order in the MAR received educational counseling for failing to properly transcribe the order.
The nurse(s) responsible for administering the [MEDICATION NAME] eye scrub was issued a disciplinary action.
II: An audit was done for residents with orders to receive medication with meals in the last 30 days to ensure all orders were entered correctly. Any identified issues were corrected.
An audit was done for all residents with orders to receive treatments in the last 30 days to ensure all treatments where given in accordance with physician orders. Any identified issues were corrected.
III: The Director of Nursing Services in conjunction with the Medical Director reviewed the facility Policy and Procedure (P&P) for Medication and Treatment Administration and found same to be compliant.
Licensed nursing staff were re-inserviced on these P&P, in particular, proper transcription of physician orders [REDACTED].
IV: The Director of Nursing Services /designee will conduct random audits of 4 residents weekly for 1 month and monthly thereafter for 5 months to ensure the facilities compliance with the provision of services in accordance with individual each resident?s plan of care. Audits with negative findings will have corrective actions taken.
Audit findings will be presented to the Quality Assurance Committee at least quarterly for review and revisions to the action plan, if warranted.
V: The Director of Nursing Services is responsible for ensuring compliance.

FF09 483.25(b):TREATMENT/DEVICES TO MAINTAIN HEARING/VISION

REGULATION: To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident in making appointments, and by arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 23, 2016
Corrected date: December 23, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview during the recertification survey, the facility did not ensure that one of three residents reviewed for Vision in a total sample of thirty Stage 2 residents received proper treatment to maintain vision ability. Specifically, Resident #153 did not have a follow-up consult with the Ophthalmologist in (MONTH) (YEAR) as recommended. The finding is: Resident #153 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 2 which indicated that the resident had severely impaired cognitive skills for daily decision making. The MDS also documented that the resident had moderately impaired vision (limited vision; not able to see newspaper headlines, but can identify objects) with no corrective lenses. On 6/2/16 the resident was seen by the Ophthalmologist. The Ophthalmologist documented that the resident had Blepharitis (an inflammation of the eyelid that affects the eyelashes or tear production) of both eyes. The Ophthalmologist also documented that the resident had a moderate Cataract of the left eye. The Ophthalmologist documented that the resident was to receive treatments of [MEDICATION NAME] eye scrub and [MEDICATION NAME] ointment to both eyes and for a follow-up in (MONTH) (YEAR) for possible Cataract surgery to improve vision. A review of the resident's medical record on 11/22/16 at 1:30 PM revealed no follow-up Ophthalmology consult. On 11/22/16 at 2:45 PM the Assistant Director of Nursing (ADON) was interviewed and stated that the Ophthalmology consult for (MONTH) (YEAR) had not been completed. The ADON further stated that the MDS Registered Nurse (RN) was responsible to generate consults. Once a consult is generated, it is left in a central location for the Consultant to collect when they enter the facility. Once a consult is completed, the MDS RN was then responsible to scan the results into the EMR (electronic medical record). On 11/23/16 at 10:30 AM the MDS RN was interviewed and stated that when she completes a MDS quarterly review, significant change, or annual review she also completes a review of the resident's medical record. The RN stated that she looks back fourteen days before the assessment to ensure that consults have been completed and that Physician Orders were written for necessary consults to be completed. The RN stated that no Physician's Order had been written for the Ophthalmologist to complete a follow-up as recommended. 415.12(3)(b)

Plan of Correction: ApprovedDecember 13, 2016

I: The facility respectfully states that resident # 153 no longer resides at the facility.
The RN responsible for documenting and arranging for the follow up consultation in (MONTH) (YEAR) received educational counselling regarding timely follow-up for Consultation recommendations and appointments.
II: A chart audit was done on all residents receiving an Ophthalmology consult in the last 6 months to identifying those who required a follow up Ophthalmology appointment. Any resident identified was seen by the Ophthalmologist.
III: The Director of Nursing Services in conjunction with the Medical Director reviewed the facility Policy and Procedure (P&P) for Consultations and found same to be compliant.
Licensed Nurses were re-inserviced by the Director of Nursing Services/designee on this P&P, in particular, the tracking of consultant follow up appointments and recommendations.
IV: The Director of Nursing Services /designee will conduct an audit of all residents seen by the Ophthalmologist, weekly for 1 month and monthly thereafter for 5 months to ensure all recommended ophthalmology follow up appointments are completed. Audits with negative findings will have corrective actions taken.
Audit findings will be presented to the Quality Assurance Committee at least quarterly for review and revisions to the action plan, if warranted.
V: The Director of Nursing Services is responsible for ensuring compliance.

Standard Life Safety Code Citations

K307 NFPA 101:HAZARDOUS AREAS - ENCLOSURE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 23, 2016
Corrected date: December 30, 2016

Citation Details

2012 NFPA 101: 19.3.2 Protection from Hazards 19.3.2.1 Hazardous Areas. Any hazardous areas shall be safe guarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. 19.3.2.1.3 The doors shall be self-closing or automatic closing. 19.3.2.1.5. Hazardous areas shall include, but shall not be restricted to, the following: 1. Boiler and fuel-fired heater rooms 2. Central /bulk laundries larger than 100ft2 (9.3 m2) 3. Paint shops 4. Repair shops 5. Rooms with soiled linen in volume exceeding 64 gallon (242L) 6. Rooms with collected trash in volume exceeding (242L) 7. Rooms or spaces larger than 50 ft2 (4.6m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction 8. Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard. Based on observation and staff interview, the facility failed to ensure that doors to hazardous areas were self-closing or automatic closing. This occurred on 2 of 3 floors of the facility. The findings are: On 11/18/2016 between the hours of 9am and 3pm during the recertification survey, the following was observed: Doors to hazardous areas were not self-closing or automatic closing. Specifically, these doors did not positively latch into their frames. The locations include but are not limited to: 1) 3rd Floor Linen Closet 2) 1st Floor Soiled Linen Closet 3) 1st Floor West Unit, Boiler Room In a concurrent interview with a maintenance worker at the time of the findings, he stated he could make adjustments to the doors. 2012 NFPA 101 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedDecember 22, 2016

The door protecting the opening to the following areas were adjusted to positively latch into their frames
? 3rd floor linen closet
? 1st floor soiled linen closet
? 1st floor west wing boiler room
The Director of Environmental Services / designee conducted an audit to ensure that doors protecting hazardous areas positively latch into their frames and have functioning self-closing devices.
The Director of Environmental Services / designee will conduct random inspections of 5 doors protecting hazardous areas weekly for 1 month and monthly thereafter for 5 months to ensure they positively latch into their frames and have functioning self-closing devices. Inspections with negative findings will have corrective actions taken.
Inspection findings will be presented to the Quality Assurance Committee at least quarterly for review and revisions to the action plan, if warranted.
The Director of Environmental Services is responsible for ensuring compliance.

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 23, 2016
Corrected date: December 30, 2016

Citation Details

2010 NFPA 10: 6.1.3.8.1 Fire extinguishers having a gross weight not exceeding 40lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Based on observation and staff interview, the facility failed to ensure that portable fire extinguishers were installed not more than 5 feet above the floor. This situation occurred on 2 of 3 floors of the facility. The findings are: On 11/18/2016 between the hours of 9am and 3pm during the recertification survey, the following was observed. Fire extinguishers were noted to be installed above 5 feet from the floor. Locations include, but are not limited to: 1) On the 3rd Floor, West Unit near the exit stair door 2) On the 3rd Floor, by the treatment room 3) On the 2nd Floor, East Unit near the exit stair door In an interview on 11/18/2016 at approximately 11:20am with the Director of Maintenance, he stated he was unaware of the requirement and will lower the fire extinguishers. 2010 NFPA 10 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedDecember 22, 2016

The fire extinguishers in the following location were relocated so that their tops do not exceed 5 feet from the floor:
? On the 3rd Floor, West Unit near the exit stair door
? On the 3rd Floor, by the treatment room
? On the 2nd Floor, East Unit near the exit stair door
The Director of Environmental Services / designee conducted an audit of all fire extinguishers to ensure that they do not exceed 40lbs and their tops do not exceed 5 feet from the floor.
The Director of Environmental Services / designee will conduct random inspections of 5 fire extinguishers weekly for 1 month and monthly thereafter for 5 months to ensure do not exceed 40lbs and their tops do not exceed 5 feet from the floor. Inspections with negative findings will have corrective actions taken.
Inspection findings will be presented to the Quality Assurance Committee at least quarterly for review and revisions to the action plan, if warranted.
The Director of Environmental Services is responsible for ensuring compliance.

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 23, 2016
Corrected date: December 30, 2016

Citation Details

Based on observation and staff interview during the recertification survey, the fire protection features of smoke barrier doors could not be determined on 2 of 3 resident use floors. The findings are: During the Life Safety Code survey on 11/18/16, between 9:00am and 3:00pm, the fire protection rating of smoke barrier doors inspected could not be determined for 2 of 3 resident use floors. There were no fire rating strips located on the fire doors, and the facility could not provide the specification for the doors that indicated they comprised of 1¾ inch solid bonded wood core. Examples included the smoke barrier doors in the following locations: East wing of the 3rd floor. East and West wings of the 2nd floor. In an interview on the same day at approximately 10:30am, the Director of Maintenance stated that he would look into getting the doors recertified if he can ' t locate the fire resistance rating of the doors. 2012 NFPA 101: 19.3.7.6, 19.3.7.8, 19.3.7.9 10 NYCRR 415.29 NYCRR 711.2(a)

Plan of Correction: ApprovedDecember 22, 2016

The facility has contracted with a recertification company to provide the missing fire rating strips located on the fire doors, or determine specification for the doors that indicate they are comprised of 1¾ inch solid bonded wood core, including the smoke barrier doors in the following locations:
? East wing of the 3rd floor.
? East and West wings of the 2nd fl
Director of Environmental Services / designee conducted an audit of all other barrier doors to ensure they either have an attached fire rating strip or compromised of 1¾ inch solid bonded wood core.
The Director of Environmental Services / designee will conduct monthly inspection of all corridor Barrier doors for 6 months. The facility shall require all replacement doors to be fire rated or compromised of 1¾ inch solid bonded wood core in any replacement or upgrades.
Inspection findings will be presented to the Quality Assurance Committee at least quarterly for review and revisions to the action plan, if warranted.
The Director of Environmental Services is responsible for ensuring compliance.