Briarcliff Manor Center for Rehabilitation and Nursing Care
October 24, 2016 Certification Survey

Standard Health Citations

FF09 483.60(b), (d), (e):DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS

REGULATION: The facility must employ or obtain the services of a licensed pharmacist who establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 21, 2016
Corrected date: December 15, 2016

Citation Details

Based on observation, interview and record review conducted during a recertification survey, the facility did not ensure that a narcotic medication was properly disposed in accordance with standard of practice to prevent possible diversion. Specifically, a Fentanyl patch, a potent narcotic analgesic, was left unattended on top of a medication cart during a medication pass observation in one of three resident halls (Unit A). The findings are: A medication pass observation was conducted on 10/17/16 at 10:15 AM on Unit A. A Fentanyl patch was observed to be unattended on top of the medication cart. The medication cart was located in the unit hallway and there was no unit staff member around or nearby to monitor the medication cart and the Fentanyl patch that was on top of the cart. At that time, the unit Licensed Practical Nurse (LPN #1) was then observed exiting a resident's room and started pouring medications for the next resident. LPN #1 was interviewed regarding the above Fentanyl patch. LPN #1 stated that it was a used patch that she removed from Resident #75. LPN #1 further stated that she did not discard the patch right away because she was waiting for another nurse to witness and co-sign disposal of the patch. The LPN then proceeded to put the used Fentanyl patch inside the medication cart. The current Individual Patient Controlled Substance Administration Record for Resident #75 revealed that the resident was receiving Fentanyl Patch 25 mcg/hour every 3 days for pain. During a follow up interview on 10/17/16 at 10:44 AM, LPN #1 stated that she should have discarded the patch with another nurse immediately after removing it from the resident's skin. Following this interview, the LPN disposed the patch with another nurse. The resident's Medication Administration Documentation History revealed that a second nurse witnessed the disposal of the Fentanyl patch as evidenced by the nurse's initials in the medication administration record. According to current standard of practice and the facility's policy and procedure, Fentanyl Transdermal Patch should be disposed of immediately, in a sharps container, once removed from a resident's skin. 415.18(d)

Plan of Correction: ApprovedNovember 23, 2016

1) LPN #1 was in-serviced followed by all Registered and Licensed Practical Nurses employed by the facility on the policy and procedure of the application, removal, and disposal of Fentanyl Patches. A facility audit was performed by the Director of Nursing and no other deficient practices were identified in reference to fentanyl patch destruction.
2) All residents have the potential to be affected by this deficient practice.
3) All Registered and Licensed Practical Nurses will be educated on the application, removal, and disposal of Fentanyl Patches upon hire and annually thereafter.
4) Residents with fentanyl patches scheduled for removal will be audited daily x3, weekly x4, monthly x3, then as needed thereafter to assure disposal of Fentanyl Patch follows facility policy and procedures for disposal. This audit will assess rendering patch unusable once removed from patient/resident, flushing the patch down the toilet immediately after removal, destruction witnessed by two nurses, and a signed Medication Administration Record [REDACTED]
5) The Director of Nursing/Designate will be responsible for this corrective action.

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: Widespread
Severity: Potential to cause more than minimal harm
Citation date: October 21, 2016
Corrected date: December 15, 2016

Citation Details

Based on observations and interviews during the recertification survey, the facility did not ensure that a freezer, a major kitchen equipment, was maintained in a safe operating condition. Specifically, the walk-in freezer did not maintain acceptable temperatures for proper food storage in accordance with standard of practice. According to the Food and Drug Administration, food stored in the freezer at 0 degrees F (Fahrenheit) or -18 degrees C (Centigrade) will maintain the safety and quality of the food. The findings are: An initial tour of the kitchen was conducted with the Food Service Director (FSD) on 10/17/16 between 9:00 AM to about 10:00 AM. The temperature log was reviewed and revealed that the temperatures recorded on 10/1/16 to 10/17/16 ranged from 13 degrees to 25 degrees F in the morning and in the afternoon/evening, the temperatures ranged from 16 to 18 degrees F. The FSD was interviewed at that time and stated that the chef takes the temperatures when he first comes in. The FSD stated that the freezer was placed in defrost mode and suggested to the surveyor to come back later to have a more accurate reading after the defrost mode period ends. At this time, the thermometer reading was 50 degrees F. The walk-in freezer was revisited by the surveyor at about 3:30 PM of the same day and it was noted that the thermometer did not go out of defrost mode. The thermometer which was placed hanging in the middle of the freezer and had the same temperature reading of 50 degrees F. The following morning on 10/18/16, the freezer was checked again by the surveyor and the FSD stated that the freezer was not working. The same food items that were observed the day before remained in the freezer overnight. Further review of the freezer temperature log for the month of (MONTH) (YEAR) revealed that the temperature ranged from 12 to 20 degrees F from 9/01/16 to 9/28/16. According to the (MONTH) (YEAR) temperature log, the freezer temperature should be less than zero degrees F. This is to ensure that the safety and quality of food is maintained. 415.5(e)(1)(2)

Plan of Correction: ApprovedDecember 1, 2016

1) The freezer was placed out of service and a new temporary freezer was delivered onsite, brought to a temperature of -5 Fahrenheit, and placed in-service.
2) All residents have the potential to be affected by this deficient practice.
3) All Food Service staff were in-serviced on freezer temperatures and the temperature logs. Freezers will be maintained at 0F or less. If freezer temperatures exceed 0F, the Director of Food Service will be notified and the facility Freezer/Refrigerator vendor will be notified for an immediate assessment. The facility maintenance department will inspect the freezer doors, coils, and compressors quarterly and be sure all components are free from rust, dust, and debris. Freezer seals will be inspected quarterly to assure appropriate seals are maintained when doors are closed. If seals are discovered damaged, they will be replaced.
4) The Freezer Temperatures will be audited twice daily; ongoing; and is to be maintained at 0F or less. The results will be reported to the Facility Quality Assurance Committee on a quarterly basis. The freezer door, coil, compressor, and seal audit will be performed monthly x3, then quarterly thereafter. All results will be reported to the facility Quality Assurance Committee.
5) The Food Service Director/Designate will be responsible for this corrective action.

FF09 483.35(i):FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY

REGULATION: The facility must - (1) Procure food from sources approved or considered satisfactory by Federal, State or local authorities; and (2) Store, prepare, distribute and serve food under sanitary conditions

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 21, 2016
Corrected date: December 15, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews conducted during a recertification survey, the facility did not ensure that the food was stored in sanitary conditions to prevent food-borne illnesses. Specifically, food was not being stored at proper freezer temperatures, multiple food items were stored beyond their expiration dates, and the household type reach-in refrigerator used to store some food items was soiled with dust, dried food particles and residue. The findings are: An initial tour of the kitchen was conducted on 10/17/16 between 9:00 AM and 10:00 AM. The following conditions were observed: 1. In the walk-in freezer which was observed to be in a defrost mode, sausage and salmon placed in a box were noted to be softening; the temperature was 50 degrees Fahrenheit; and vanilla nutrition cups in a carton were defrosted. 2 . Multiple foods items with the expiration dates inscribed on the food labels and covers were found to be stored in an area of the cellar. - Thickened apple juice - 9/2016 - Cranberry juice - 9/2016 - Almond milk in a carton (non-refrigeration required) - 9/17/2016 - [MEDICATION NAME] (feeding formula) - 9/1/2016 - Chinese noodles - 10/2015 - Glucerna (nutritional supplement) - 7/1/2016 - Instant oatmeal - 5/30/16 - Mustard - 4/23/16 3. Several food items were stored in a house type reach-in refrigerator. Interview with the Food Service Director (FSD) at the time of observation stated that the food items were not in use. The food items included blocks of cheese, bags of unopened and shredded cheese. The temperature reading in the refrigerator was 40 degrees. There was no temperature log to monitor the temperature of the refrigerator. This reach-in refrigerator was soiled with dust, dried food particles and whitish / brown residue, especially on the door shelves. The freezer compartment had spillage of an unknown dried substance. 4. The walk-in freezer had sticky liquid and dried solid debris on the floor The FSD was interviewed on 10/17/16 at 9:40 AM on 10/17/16 and stated that that the freezer is cleaned weekly,. Additionally, further observation revealed soiled wash rags placed on top of an opened and exposed box of foil wraps. 415.14 (h)

Plan of Correction: ApprovedNovember 23, 2016

1) All foods in freezer and refrigerator were discarded, and expired foods located in cellar were also discarded. Both the freezer and refrigerator were sanitized and removed from service. A temporary freezer was delivered and replacement food was ordered. The temporary freezer will remain in place until the facility freezer is repaired which will be by 12/10/2016. The facility freezer temperature will be monitored and is not to exceed 0F.
2) All residents have the potential to be affected by this deficient practice.
3) All Food Service Staff have been in-serviced on freezer and refrigerator storage temperatures and logs. Freezer temperatures will be maintained at 0F and refrigerator temperatures will be maintained at 41F. Food service staff will also been in-serviced on food service sanitation, maintaining clean and sanitized freezers/refrigerators, and discarding expired food products.
4) All freezer and refrigerators will be audited daily x5, weekly x4, monthly x3, then as needed thereafter and will include freezer/refrigerator temperatures, assessment of cleanliness, and assessment of storage with approved coverings/dates and will be reported to the facility Quality Assurance Committee. Dry food storage areas will be audited daily x5, weekly x4, monthly x3, then as needed thereafter and will include expiration date assessments of food products, 6 inch off the floor/storage rack assessments, and food storage area floor/wall cleanliness.
5) The Food Service Director/Designate will be responsible for this corrective action.

Standard Life Safety Code Citations

K201 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Smoke barriers are constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. Smoke barriers may terminate at an atrium wall. Windows are protected by fire-rated glazing or by wired glass panels and steel frames. A minimum of two separate compartments are provided on each floor. Dampers are not required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems. 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 21, 2016
Corrected date: December 15, 2016

Citation Details

2000 NFPA 101: Chapter 8 Features of Fire Protection 8.2.3.2.3* Opening Protectives 8.2.3.2.3.1 Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier wall to the other. The fire protection rating for opening protectives shall be as follows: (1) 2 - hour fire barrier ---1 ½ hour fire protection rating (2) 1- hour fire barrier --- 1- hour fire protection rating where used for vertical openings or exit enclosures, or ¾ -hour fire protection rating where used for other than vertical openings or exit enclosures, unless a lesser fire protection rating is specified by Chapter 7 or Chapters 11 through 42. (3) ½ hour fire barrier--- 20 minute fire protection rating Based on observation, staff interview and documentation review, the facility did not ensure that the openings in smoke barriers were provided with construction that restricts the movement of smoke from one side of the smoke barrier to the other. This was evidenced by the doors in smoke barrier walls that did not fully close to resist the passage of smoke. This was noted on 1 of 2 resident floors. The findings are: During the life safety tour conducted on 10/18/16 and 10/19/16 between the hours of 11:00 AM - 3: 00 PM, smoke barrier doors were examined and the following issues were noted: - The smoke barrier door near the kitchen on the first floor was examined at approximately 12:10 PM. It was noted at this time that one of the two door leaves did not fully close. An approximately 1.5 inch gap was noted between the doors. In addition, the wood on the surface of the door was in disrepair in that pieces of wood were peeling off the door. - At approximately 1:50 PM, the smoke barrier doors on the A even corridor were examined. It was noted at this time that there was an approximately quarter of an inch gap between the two leaf doors. In an interview at the time of the findings, the Director of Maintenance stated that the opening in the door was due to the air from the kitchen exhaust fan. It was noted in the facility logbook for the smoke barrier doors that the smoke barrier doors near the dining room need to be replaced. 2000 NFPA 101: 8.3.6, 19.3.7.5 10 NYCRR 711.2(a)(1)

Plan of Correction: ApprovedNovember 11, 2016

1. The smoke barrier doors located near the kitchen on the first floor have been replaced and adjusted to create a sealed compartment when the doors are closed.
2. All smoke barrier doors were inspected throughout facility. All smoke barrier doors were adjusted to create a sealed smoke barrier when doors are closed.
3. All smoke barrier doors have been placed on a monthly facility inspection report and will be addressed and adjusted if discovered not to be in compliance with 2000 NFPA 101: Chapter 8.
4. All smoke barrier doors throughout the facility will be audited weekly x4, then monthly thereafter. Results of the audit will be submitted to the facility Quality Assurance Committee.
5. The Director of Maintenance will be responsible for this corrective action.

K201 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Exit components (such as stairways) are enclosed with construction having a fire resistance rating of at least one hour, are arranged to provide a continuous path of escape, and provide protection against fire or smoke from other parts of the building. 8.2.5.2, 19.3.1.1

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 21, 2016
Corrected date: December 15, 2016

Citation Details

Based on observation and staff interview, the facility failed to ensure that exit enclosures (such as stairways) are enclosed with construction having a fire resistance rating of at least one hour, are arranged to provide a continuous path of escape, and provide protection against fire or smoke from other parts of the building. This was noted in four of five stairwell. The findings are: On 10/19/16 between the hours of 11:00 AM - 3:00 PM, the following issues in the stairwells were noted: - At approximately 11:00 AM, a tour of the West stairwell second floor landing revealed a missing ceiling tile and an unsealed wire penetration in the concrete wall. In an interview at the time of the findings, the Director of Maintenance stated that the wire is for the new key pads that will be installed in approximately two weeks. - At approximately 11:35 AM, a tour of the second floor South stairwell revealed a sweeper attached to the bottom of the stairwell door preventing the door from closing. - At approximately 11:55 PM, a tour of the North stairwell from the dining room on the first floor was conducted. It was noted that the stairwell has a door within the stairwell that leads to the basement area. This door did not latch upon self-closing. The door rested on the frame. - At approximately 1:30 PM, a tour of the first floor landing of the East stairwell revealed that the door did not latch in the frame upon self-closing. In an interview at the time of the findings, the Director of Maintenance stated that the stairwell doors are checked quarterly. 2000 NFPA 101: 7.1.3.2, 8.2.5.2, 8.2.5.4, 19.3.1.1 10 NYCRR 711.2(a)(1)

Plan of Correction: ApprovedNovember 15, 2016

1. The ceiling tile was replaced and the penetration was sealed with fire caulk in the west stairwell. The sweeper was adjusted on the south stairwell door to assure the door closed and positively latched. The doors in the north and east stairwells were adjusted to assure a positive latch when closed.
2. All doors have the potential to become off-centered and all ceiling tiles have the potential to not be replaced. All areas of installation have the potential to leave penetrations in the fire/smoke barrier walls.
3. All doors in the facility have been added to the monthly maintenance facility inspection report. If a door is discovered off center, it will be immediately corrected to ensure a positive latch. Ceiling tiles inspections have been added to the facility monthly maintenance inspection report and will be replaced immediately if discovered missing. All areas of potential wire penetration will be inspected, corrected immediately if a penetration is discovered, and inspected after any installations are completed which required to penetrate a fire/smoke barrier wall. If a penetration is discovered, it will be filled with fire caulk.
4. All doors in the facility will be audited monthly x3, then quarterly thereafter to ensure closure with a positive latch. All ceiling tiles in the facility will be audited monthly x3, then quarterly thereafter. All potential firewall penetration areas will be inspected monthly x3, quarterly thereafter, and after any installations requiring penetration of the fire/smoke barriers. All results will be submitted to the facility Quality Assurance Committee.
5. The Director of Maintenanace will be responsible for this corrective action.

K201 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Stairways and smokeproof towers used as exits are in accordance with 7.2. 19.2.2.3, 19.2.2.4

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 21, 2016
Corrected date: December 15, 2016

Citation Details

2000 NFPA 101 7.2.2.5 Enclosure and Protection of Stairs 7.2.2.5.3* Usable Space. There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress. Based on observation and interview, it was determined that the facility did not ensure that the means of egress were maintained free of combustible storage that would afford safe and unobstructed usage of the stairwell by the building occupants. This is evidenced by metal and plastic storage noted in 1 of 5 stairwells. During the life safety code survey conducted on 10/19/16 at approximately 11:25 AM, an examination of the PT / OT emergency exit revealed metal and plastic handrails stored under the bottom landing and between the first and second floor landing. In an interview at the time of the findings, the Director of Maintenance stated that the contractors stored the items in the stairwell. 2000 NFPA 101: 19.2.1 711.2(a)(1)

Plan of Correction: ApprovedNovember 11, 2016

1. All stored items were immediately removed from both landings located in the stairwell.
2. All emergency exit hallways and stairwells were inspected and found to be clear of stored building materials and debris.
3. All maintenance staff and contracted workers were in-serviced on building material storage areas and to maintain hallways and stairwells clear of materials.
4. All stairwells will be audited daily x5, weekly x4, then monthly thereafter to maintain compliance with 2000 NFPA 101:19.2.1 711.2(A)(1). The results of the audit will be submitted to the Quality Assurance Committee.
5. The Maintenance Director will be responsible for this corrective action.

K201 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Exit access is arranged so that exits are readily accessible at all times in accordance with section 7.1. 19.2.1

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 21, 2016
Corrected date: December 15, 2016

Citation Details

2000 NFPA 101 Life Safety Code 7.1.10 Means of Egress Reliability. 7.1.10.1 * Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency. Based on observations and interview, the facility did not ensure that all required exit passageways are maintained readily accessible at all times and free of all obstructions or impediments to full instant use in the case of fire or other emergencies in accordance with NFPA 101. This was evidenced by broken concrete in the egress path at the North stairwell exit discharge and an exit passageway from the Center Stairwell that was unpaved. The findings are: On 10/18/16 between the hours of 11:00 AM and 3:00 PM, the following issues were noted: - At approximately 1:45 PM an examination of the emergency exit from the North stairwell revealed that the concrete between the exit door and the pathway was cracked and broken in several pieces. This emergency exit discharges to a public way. - At approximately 2:15 PM an examination of the emergency exit from the center stairwell revealed that a section of the pathway was unpaved. This pathway measured approximately 83 ft. long and leads to a public way. This situation would not ensure the safe, instant use of this path of egress. In an interview at the time of the findings, the Director of Maintenance could not provide an explanation. The Director of Maintenance stated that the damaged concrete and the pathway from the emergency exit will be cleared. 2000 NFPA 101: 19.2, 7.1.10, 7.1.10.1 10 NYCRR 711.2(a)(1)

Plan of Correction: ApprovedNovember 22, 2016

1. The concrete between the door and the pathway was replaced from the north stairwell and the pathway will be paved from the center stairwell to ensure a safe instant use of pathway egress in accordance with NFPA 101.
2. All exit paths of egress have the potential to be non compliant with NFPA 101.
3. All exit paths of egress will be placed on the monthly facility maintenance inspection report and will be immediately addressed if found to be non compliant with NFPA 101.
4. All exit paths of egress will be inspected and audited monthly. The results of these audits will be submitted to the facility quality assurance committee.
5. The Director of Maintenance will be responsible for this corrective action.

K201 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 21, 2016
Corrected date: December 15, 2016

Citation Details

1998 NFPA 25: Chapter 4 Private Fire Service Mains 4-2.2.4 Dry Barrel and Wall Hydrants Dry barrel and wall hydrants shall be inspected annually and after each operation. Hydrants shall be inspected, and the necessary corrective action shall be taken as shown in Table 4-2.2.4 Based on observation and interview, the facility did not ensure that the five dry barrel hydrants are tested , inspected and maintained in accordance with NFPA 25. This was evidenced by a lack of service reports for the five hydrants noted on the premises. The findings are: On 10/19/16 at approximately 12:10 PM, the hydrant near the entrance of the building was observed with a cap missing. In an interview at approximately 1:05 PM, the Director of Maintenance stated that the facility is waiting for a thread part to place on the hydrant. The last inspection report was requested. The Director of Maintenance stated that he will obtain the report. 1998 NFPA 25: 4-2.2.4 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedNovember 22, 2016

1. The cap will be replaced on the hydrant near the entrance to the building. All five (5) barrel hydrants will be inspected annually and after each operation by the facilities licensed fire protection vendor. All dry barrel hydrants will be maintained in accordance with NFPA 25. The facility will maintain documentation of the inspection reports.
2. All dry barrel hydrants have the potential to be affected by this deficient practice.
3. All dry barrel hydrants will be tested and inspected annually and after each operation.
4. The results from the respective testing company which services the five dry barrel hydrants will be submitted after their inspection in addition to an audit which will be performed by the facility Maintenance Director on the integrity of the dry barrel hydrant caps monthly x3.
5. The Maintenance Director will responsible for this corrective action.

K201 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 21, 2016
Corrected date: December 15, 2016

Citation Details

2000 NFPA 101 LSC Chapter 9.1 UTILITIES 9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction. 1999 NFPA 70 Article 305 - Temporary Wiring, Section 305-2. All Wiring Installations (a) Other Articles. Except as specifically modified in this article, all other requirements of this Code for permanent wiring shall apply to temporary wiring installations. (b) Approval. Temporary wiring methods shall be acceptable only if approved based on the conditions of use and any special requirements of the temporary installation. Article 400 - Flexible Cords and Cables 400-8. Uses Not Permitted Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following: 1. As a substitute for the fixed wiring of a structure 2. Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors 3. Where run through doorways, windows, or similar openings 4. Where attached to building surfaces 5. Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors 6. Where installed in raceways, except as otherwise permitted in this Code. 1999 NFPA 70 Article 110-12. Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner. 1999 NFPA 99: 3-3.2.1.2(d) 2- Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters. Based on observation and interview, the facility did not ensure that multiple adapters were not in use in accordance with the National Electrical Code (NFPA 70), as evidenced by patient care equipment plugged into the multiple adapters and that all electrical wiring and telephone cables in the air conditioning equipment rooms located on 1 of 2 residents floors had been installed in a neat and workmanlike manner. This was evidenced by the electrical wires and telephone cables that were observed hanging from the ceiling and strewn throughout the room. The findings are: During the life safety tour conducted on 10/18/16 and 10/19/16 between 11:00 AM - 3:00 PM, the following issues were noted: - At approximately 11:15 AM, a tour of resident room C 14 was conducted. It was noted at this time that there were two multiple adapters that were secured to the electrical outlets in the room. The bed, feeding pump, and air mattress were plugged into the multiple adapter on the A side of the room. The bed and a nebulae machine were plugged into the multiple adapter on the B side. In an interview at the time of the findings, the Director of Maintenance stated that the multiple adapters in the room were missed by staff when the facility was removing the multiple adapters from resident rooms. - On 10/18/16 at approximately 11:40 AM, a tour of the air conditioning equipment room located on the 2nd floor near the nursing station was conducted. Examination of the room revealed several ceiling tiles missing and bundles of computer and telephone cables were hanging from the middle of the ceiling in several areas of the room. In an interview conducted at the time of the finding, the Director of Maintenance stated that some of the wires are old and must be removed. 2000 NFPA 101: 19.5.1, 9.1.2 1999 NFPA 70: Article 110-12, Article 400-8 1999 NFPA 99: 3-3.2.1.2(d) 2 10 NYCRR 711.2(a)(1)

Plan of Correction: ApprovedNovember 22, 2016

1. The multiple electrical adapter outlets were immediately removed from the rooms and all equipment requiring power were plugged into existing wall outlets. The computer and telephone wires will be cable tied and relocated in a neat and workmanlike manner in the air-conditioning room located on the 2nd floor. All ceiling tiles will be re-installed.
2. All electrical outlets throughout the facility were inspected and found to be in compliance. No additional electrical adapter outlets were discovered. All mechanical rooms have the potential to have installation defaults including poor wiring practices and failure to replace ceiling tiles.
3. All staff will be in-serviced on the prohibition of unapproved power strips and extension cords. All residents and families will be in-serviced on the prohibition of power strip use and extension cords during their respective councils. A notice will be placed in the new admission packets, and a mailing will be sent annually to respective healthcare proxies and point of contacts. All mechanical rooms will be inspected and all cable and telephone wiring will be inspected to assure they are installed in a neat and workman like manner. All ceiling tiles will be installed if discovered missing in all areas. Mechanical Rooms also be inspected daily and logged on the facility daily facility maintenance inspection report.
4. The Director of Maintenance will audit all electrical outlets throughout the facility weekly x4, then monthly thereafter and report results to the Quality Assurance Committee of the facility. Mechanical Rooms will be audited weekly x4, then monthly thereafter to assure all wiring and ceiling tiles are installed in a neat and workman like manner. These results will also be submitted to the facility Quality Assurance Committee.
5. The Director of Maintenance will be responsible for this corrective action.

K201 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Rubbish Chutes, Incinerators and Laundry Chutes: (1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor is sealed by fire resistive construction to prevent further use or is provided with a fire door assembly having a fire protection rating of 1 hour. All new chutes comply with section 9.5. (2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, is provided with automatic extinguishing protection in accordance with 9.7. (3) Any trash chute discharges into a trash collection room used for no other purpose and protected in accordance with 8.4. (4) Existing flue-fed incinerators are sealed by fire resistive construction to prevent further use. 19.5.4, 9.5, 8.4, NFPA 82

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 21, 2016
Corrected date: December 15, 2016

Citation Details

2000 NFPA 101 - 9.5 Rubbish Chutes, Incinerators, and Laundry Chutes. 9.5.2 Installation and Maintenance. Rubbish chutes, laundry chutes, and incinerators shall be installed and maintained in accordance with NFPA 82, Standard on Incinerators and Waste and Linen Handling Systems and Equipment, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction. Based on observation and interview, the facility did not ensure that the doors to the soiled linen chutes are maintained self-closing and or latching within the soiled utility rooms, in accordance with NFPA 82. This was evidenced by the door to the laundry chutes on one of two resident floors that did not latch in the frame when closed. The findings are: During the life safety tour of the facility on 10/18/16 at approximately 11:45 AM, a tour of the soiled linen chute room located on the first floor was conducted and it was noted that the door to the linen chute did not latch firmly in its frame after self-closing. A latching mechanism was not installed on the door. In an interview at the time of the finding, the Director of Maintenance stated that the doors to the chutes are checked quarterly. 1999 NFPA 82 10 NYCRR 711.2(a)(1)

Plan of Correction: ApprovedNovember 22, 2016

1. No residents have been affected by this deficient practice. The linen chute located on the 1st floor will have a new latching mechanism installed to assure positive latching after self closing.
2. Both linen chute hinges/latches have the potential to become off-center/damaged causing a failure to positively latch.
3. The Maintenance Director has added the linen chute to their monthly environmental maintenance check list.
4. The Maintenance Director will Audit the Chutes Monthly x3 and as indicated thereafter to assure a positive latch on the linen chute doors after self closing.
5. The Maintenance Director or his/her designate will be responsible for the correction of this deficiency.

ZT1N 415.29:PHYSICAL ENVIRONMENT

REGULATION: N/A

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 21, 2016
Corrected date: December 15, 2016

Citation Details

415.29 Physical environment. The nursing home shall be designed, constructed, equipped and maintained to provide a safe, healthy, functional, sanitary and comfortable environment for residents, personnel, and the public. (h) Ventilating, heating, and air conditioning systems. Such systems shall: (1) be maintained in good repair and shall be operated in a manner which will not allow for the spread of infection and provide for resident health and comfort; and (2) be maintained and operated in such manner that air shall not be circulated from resident isolation rooms, laboratories in which work is done in pathology, virology or bacteriology, autopsy rooms, kitchen and dishwashing areas, toilet and bath rooms, janitors' closets and soiled utility rooms or soiled linen rooms, to other parts of the facility. Based on observation, interview, and documentation review, it was determined that the heating, ventilating, and air conditioning (HVAC) system was not maintained as per 90 A. This was evidenced by the mechanically operated louvers in the set of doors from the main boiler room and the rusted louvers observed on the single exit discharge door from the boiler room located within the rehab room. The findings are: On 10/19/16 at approximately 10:40 AM a tour of the boiler room was conducted. It was noted at this time that there was a set of double doors located at the rear of the boiler room that exit to a public way. These doors have open louvers that measured 36 x 92. At approximately 2:55 PM, further examination of the two doors in the boiler room revealed that the electrical cords for the mechanically operated louvers were not connected to the electrical outlets to function as designed. A request was made for the last inspection, maintenance and test report for the mechanically operated louvers. In an interview at the time of the findings, the Engineering staff member could not provide an explanation as to why the electrical cords for the motorized dampers were not plugged into an outlet. - At approximately 1:30 PM, a tour of the second boiler room located in the Rehab area was toured. It was noted that rear door from the boiler room contains louvers. The louvers were observed closed, rusted and measure approximately 30 x 24. The discharge exit from this room opens to an egress pathway which leads to a public way. 415.29(h)(1)(2) 10 NYCRR 711.2(a)(1)

Plan of Correction: ApprovedNovember 22, 2016

1. New doors with louvers will be installed at both the rear of the boiler room and also in the additional boiler room located in the rehabilitation area. The louvers and the doors in the boiler room where the generator is located will remain in the closed position until the generator is activated. These louvers are powered by outlets which energize when the generator activates. Once the generator is activated it will power the louvers on the doors to open to allow for air to enter the boiler room and cool the generator. The louvers on the doors located in the boiler room nearest the rehabilitation area will remain in the open position until the installed fusible link is activated causing the louvers to close. The louvered doors located in the boiler room where the generator is located will be checked daily to assure that generator power is connected so louvers will operate when required and they will also be checked by the maintenance department after any outside contractor performs repairs in the boiler room to assure generator power remains connected. Maintenance staff were in-serviced on the operation of door louvers, both generator and fusible link operated.
2. There are no other louvered doors located in the facility.
3. All doors located in the facility will be placed on the monthly maintenance facility inspection report. All louvers will be checked to assure they operate and are free from rust on a daily basis and after any outside contractor performs repairs in any of the boiler rooms.
4. The louvered doors will be audited monthly x3 then quarterly thereafter. The results will be submitted to the facility Quality Assurance Committee.
5. The Maintenance Director will be responsible for this corrective action.