Comprehensive Rehabilitation and Nursing Center at Williamsville
October 16, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.70:ADMINISTRATION

REGULATION: 483.70 Administration. A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 16, 2018
Corrected date: December 14, 2018

Citation Details

Based on interview and record review conducted during the Standard survey completed on 10/16/18, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the administrator did not ensure a facility assessment was completed, an antibiotic stewardship program was initiated, baseline care plan summaries were provided to residents or their representative, and that transfer/discharge notices were sent to a representative from the Office of the State Long-Term Care Ombudsman. In addition, the Administrator did not ensure implementation of a Legionella culture sampling and management plan, did not ensure mechanical, electrical and patient care equipment was maintained in safe operating condition, and did not ensure the building's elevator was properly maintained. The findings are: Refer to F 623 Notice Requirements Before Transfer/Discharge - Scope/Severity (S/S) = B Refer to F 655 Baseline Care Plan - S/S = E Refer to F 838 Facility Assessment - S/S = D Refer to F881 Antibiotic Stewardship Program - S/S = B Refer to F 908 Essential Equipment, Safe Operating Condition - S/S = E Refer to K 531 Building Services - Elevators - S/S = D Refer to I 210 Infection Control- Legionella - S/S = E 1. a.) The facility did not ensure that a written summary of the baseline care plan, that included initial goals, a list of current medications, dietary instructions, and services/ treatments to be administered by facility and personnel acting on behalf of the facility, was provided to the resident or the resident's representative. During an interview on 10/12/18 at 10:18 AM, the DON stated, Social Work should be providing the residents with the baseline care plan when they come in, when they are doing their interviewing. I do not know if it has been being done. Nursing has not been providing the baseline care plans. There is a care plan that goes around when they are first admitted for the first two days, that each discipline needs to complete. They are brought at morning report. We do not have a policy for the baseline care plans. That is one policy we never made when the new regulations came out last November. During interview on 10/15/18 at 3:05 PM, the Administrator stated he was aware of the new regulations for baseline care plans, but he prioritized and wanted to focus on providing quality of care first. b. The facility did not send a copy of the discharge notice to the Office of the State Long Term Care (LTC) Ombudsman. During an interview on 10/15/18 at 9:45 AM, Social Worker #1 stated, I do not contact the Ombudsman when a resident is discharged or goes to the hospital. I am the Social Worker for long term care, not rehab. I need to read the new regulations, I guess. I did not know this is a requirement. During an interview on 10/15/18 at 9:45 AM, the Director of Social Work stated, I have only been here since (MONTH) and have been gone the past two weeks. I do not know how they were doing this prior to me starting. Since I have been here I have not been sending notifications to the Ombudsman. I need to get in contact with the new Ombudsman as to the way she wants it sent. I do not know if we have a policy for notifying the Ombudsman when a resident is admitted , discharged or transferred. During interview on 10/15/18 at 3:05 PM, the Administrator stated he was aware of the new regulations for discharge notification to ombudsman but he prioritized and wanted to focus on providing quality of care first. c.) During an interview on 10/10/18 at 1:57 PM the administrator stated they do not have a completed facility assessment. On 10/11/18 the Administrator presented a copy of an undated Facility Assessment Tool. Review of the undated Facility Assessment Tool, revealed there was no documented evidence that a complete assessment of the resident population considering the types of diseases, condition, physical and cognitive disabilities, and overall acuity was done. Additionally, there was no documented evidence or incomplete information that other facility resources, including, special care and services offered based on the residents' needs, contracts or other agreements with third parties to provide services or equipment to the facility and health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations were addressed. During interview on 10/15/18 at 3:05 PM, the Administrator stated he was aware of the new regulations for a facility assessment, discharge notification to ombudsman and the baseline care plans, but he prioritized and wanted to focus on providing quality of care first. d.) The facility did not implement an antibiotic stewardship program. During an interview on 10/15/18 at 1:18 PM, the Director of Nursing (DON) stated, there is not an Antibiotic Stewardship Program, a policy or tracking process of antibiotic use in the facility at this time. The DON further stated she was aware of the new regulation for an antibiotic stewardship program but has not had time to start the program. During an interview on 10/16/18 at 9:07 AM, the Administrator stated, he was aware there was an antibiotic stewardship program regulation, but was not familiar with it and didn't know the facility did not have an antibiotic stewardship program in place. e.) The facility did not maintain all essential mechanical, electrical and patient care equipment in safe operating condition. Issues included shower plumbing devices and hoses that did not have vacuum breakers to prevent backflow, open sewer plumbing, sewer plumbing that was leaking sewage into the building, and plumbing pipes were leaking water into the building. During an interview on 10/15/18 at 3:05 PM, the Administrator stated he was aware of the sewage leaks in the building and the sewage problem had started a couple weeks ago. The building had other plumbing issues in the past that the facility had addressed previously but they were not to the extent that the current pluming issue. The Administrator also stated, the facility had a lot of other things going on and he had to prioritize what got taken care of first. The Administrator also stated the facility had come along way and addressed many issues. 2. The building's elevator was not properly maintained. Issues included: the in-car bell alarm was not operational, no load safety testing was due, the five-year, full load, rated speed safety test was overdue, and the bottom run by of cars and counterweights needed ropes to be shortened and then retested . Record review of an elevator inspection and test report dated 9/18/18 revealed: -The following old repeat violations shall be addressed. -the in-car alarm bell was not operational (originally cited on 1/2/18) -no load safety testing was due (originally cited on 1/2/18) -five-year, full load, rated speed safety test was overdue (originally cited on 1/2/18) -the bottom run by of cars and counterweights needed ropes to be shortened and then retested . (originally cited on 2/28/17) During an interview on 10/15/18 at 3:05 PM, the Administrator stated he was not aware the elevator had outstanding deficiencies that had not been corrected. 3. Review of the facility's Legionella Risk Assessment, with a completion date of (MONTH) (YEAR), revealed it contained no documentation for the adoption or implementation of a Legionella culture sampling and management plan for the building's potable water system. During an interview on 10/15/18 at 3:05 PM, the Administrator stated he was aware of the Legionella regulations but the facility had a lot of other things going on and he had to prioritize what got taken care of first. The Administrator also stated the facility had come along way and had addressed many issues. 415.26

Plan of Correction: ApprovedNovember 26, 2018

1a) Base line care plans will be developed and given to the Resident or Resident's representative.
1b) The Ombudsman has been given a list of all discharges for the past six months and has been added to the facility Resident discharge email list.
1c) A complete Facility Assessment was completed and reviewed with the leadership team.
1d) An Antibiotic Stewardship Program was developed and implemented.
1e) The sewer pipe was fixed and the issue was resolved.
2a) An elevator service company was called in to fix all old repeat deficiency.
3a) A facility Legionella risk assessment was developed for facility practice.

2. The Administrator and Director of Nurses acknowledge the new regulations and requirements and agree to adhere to the facility initiatives developed. The Administrator and Director of Nurses will monitor the areas identified for completion, implementation and continued compliance. The Administrator, Director of Nurses and leadership team will be re-educated by the Quality Assurance Consultant to these requirements.

3. The plan of correction established for F 623, F655, F838, F881, F908, K 531 and I 210 will be audited additionally by the consultant every quarter for continued validation of compliance with the plan of correction submitted. Each department director responsible for any one deficiency cited will be monitored monthly by the Administrator and or Director of Nurses for complying with the plan of correction submitted. The facility consultant will monitor this plan.

4. On a quarterly basis the facility consultant will present the findings of the independent audits completed as it relates to the cited deficiencies and will report to the QA committee the degree of compliance to the plan of correction submitted. Quarterly audits will continue until the QA committee recommends otherwise. The Administrator and Director of Nurses will supervise each department for compliance to the plan of correction submitted. Quality Assurance Consultant will be responsible for corrective actions to be implemented for this deficiency.

FF11 483.80(a)(3):ANTIBIOTIC STEWARDSHIP PROGRAM

REGULATION: 483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: 483.80(a)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 16, 2018
Corrected date: December 14, 2018

Citation Details

Based on interview and record review conducted during the Standard Survey completed on 10/16/18, the facility did not establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. Specifically, the facility did not implement an antibiotic stewardship program. The finding is: 1. During an interview on 10/15/18 at 1:18 PM, the Director of Nursing (DON) stated, there was not an Antibiotic Stewardship Program, a policy, or tracking process of antibiotic use in the facility at this time. The DON further stated she was aware of the new regulation for an antibiotic stewardship program but has not had time to start the program. During an interview on 10/16/18 at 9:07 AM, the Administrator stated, he was aware there was a regulation specific to an Antibiotic Stewardship Program, but was not familiar with it and didn't know the facility did not have an antibiotic stewardship program in place. 415.19(a)(1,3)

Plan of Correction: ApprovedNovember 9, 2018

1a) An Antibiotic Stewardship Program was developed with the Medical Director that includes antibiotic use protocols and a system to monitor antibiotic use.
2. The facility will develop a policy on Antibiotic use and educate each licensed nurse, physician and physician extender to the specific facility protocol. The protocol will be implemented immediately. The facility RN Educator will create a post test for all licensed staff and orient all new licensed employees to this facility program.

3. Each month the facility RN Educator will review all residents receiving antibiotics and review if the stewardship program was followed and document the findings of the review be reviewed with the Director of Nurses. Any trends identified to indicate the program is not being followed will be addressed with the specific individual and noted on the monthly review. The RN Educator will monitor the compliance of this stewardship program on a monthly basis.

4. At the monthly facility QA meeting, the RN Educator will present the findings of the monthly antibiotic program and communicate the compliance of following the facility program. This monthly review will be on-going. The antibiotic program will be reviewed on a quarterly basis with the Medical Director and Director of Nurses to modify and expand the facility protocol. The minutes of the antibiotic stewardship quarterly review meeting will be entered into the QA minutes. The Director of Nurses will supervise this plan.

FF11 483.21(a)(1)-(3):BASELINE CARE PLAN

REGULATION: 483.21 Comprehensive Person-Centered Care Planning 483.21(a) Baseline Care Plans 483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must- (i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to- (A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. 483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan- (i) Is developed within 48 hours of the resident's admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section). 483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 16, 2018
Corrected date: December 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard survey completed on 10/16/18, the facility did not ensure that a written summary of the baseline care plan, that included initial goals, a list of current medications, dietary instructions, and services/ treatments to be administered by facility and personnel acting on behalf of the facility, was provided to the resident or the resident's representative. Six (Residents #48, 49, 85, 86, 98, and 100) of six newly admitted residents reviewed for baseline care plans had no documented evidence that a written summary of the baseline care plan was provided to the resident and the resident's representative by completion of the comprehensive care plan. The findings include but are not limited to: 1. Resident #49 was admitted into the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 8/13/18 revealed the resident was cognitively intact and was understood and understands. Review of the progress notes dated 5/12/18 through 10/15/18 revealed there was no documented evidence that a copy of the resident's baseline care plan was provided to the resident or a resident representative. During an interview on 10/10/18 at 8:32 AM, Resident #49 stated, I do not think they gave me a copy of my care plan when I was admitted here. During an interview on 10/11/18 at 11:57 AM, the Registered Nurse (RN #1) Unit Coordinator stated, I have not given out any baseline care plans upon admission, unless the resident specifically asks for it. I spoke with the Director of Nursing (DON)and she does not know who would be providing the baseline care plans. During an interview on 10/12/18 at 10:01 AM, Social Worker #1 stated, We do not provide the resident or the family with a copy of the baseline care plan when they are admitted . We do fill out an interim care plan within 48 hours, but that just gets placed in the chart. During an interview on 10/12/18 at 10:03 AM, Director of Social Work (SW#2) stated, I just started in (MONTH) and then I was on vacation for 2 weeks in September. I do not believe we provide a copy of the care plan to the resident or family. Maybe nursing provides them. During an interview on 10/12/18 at 10:18 AM, the DON stated, Social Work should be providing the residents with the baseline care plan when they come in, when they are doing their interviewing. I do not know if it has been being done. Nursing has not been providing the baseline care plans. There is a care plan that goes around when they are first admitted for the first two days, that each discipline needs to complete. They are brought at morning report. We do not have a policy for the baseline care plans. That is one policy we never made when the new regulations came out last November. 2. Resident #85 was admitted into the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed that the resident was severely cognitively impaired and was understood and understands. Review of the progress notes dated 8/21/18 through 10/15/18 revealed there was no documented evidence that a copy of the resident's baseline care plan was provided to the resident or a resident representative. During an interview on 10/15/18 at 10:53 AM, SW #1 stated, No I did not give his wife a baseline care plan upon admission 8/21/18. 3. Resident #48 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) dated 8/10/18 documented the resident was cognitively intact and was understood and usually understands. Review of an admission interim care plan (base line care plan) dated 8/3/18 revealed there was no documented evidence the resident's base line care plan was reviewed or provided to the resident. Review of the Progress Notes from 8/2/18 through 9/2/18 revealed there was no documented evidence a base line care plan was reviewed with the resident or family and / or copies provided to the resident or family. Review of Social Services Progress Notes dated 8/2/17 through 9/2/18 revealed there was no documented evidence the resident's base line care plan was reviewed or provided to the resident. During an interview on 10/10/18 at 9:03 AM, Resident #48 stated, I have never met with nursing about my medication or have been invited to a care plan meeting. I would go if I was invited. During an interview on 10/12/18 at 12:53 PM, the Director of Social Work (SW #2) stated the facility has not been providing the resident or family member with a care plan. During a follow up interview on 10/12/18 at 2:20 PM, she stated she did not review the base line care plan with this resident. During an interview on 10/15/18 at 11:38 AM, Registered Nurse (RN #1) stated a base line care plan was completed, but she does not provide copies to anyone. Additionally, she could not recall reviewing the baseline care plan with this resident. 415.11(c)(1)

Plan of Correction: ApprovedNovember 26, 2018

1. Resident # 49, 83 and #48 will be contacted and their initial care plan reviewed if still residing at the facility.
2. All admissions still residing at the facility, within the last thirty days will have their initial care plans reviewed with the residents by SW and the Unit Manager. A confirmation receipt will be placed in the medical record under care plan.
3. SS and Nursing Administration will be re-educated by the facility staff educator (RN). to the requirement that initial care plans are to be reviewed with the resident within forty-eight hours of admission and re-admission. The facility will modify the policy and assign account abilities. A running audit will be maintained by SS for every resident and when they receive their initial care plan. The medication list will be reviewed with the resident by the Admission nurse or designee. At the end of the month, the running audit completed by SS will be compared to the admission report in PCC to determine compliance. The Director of SS to monitor.
4. The Director of SS will present at the monthly QA meeting the number of admissions and the number of initial care plans distributed within forty-eight hours and those outside the target date. The running monthly audit by SS will continue monthly times three months if 100% compliance is achieved for two months. The QA committee will make comments and or recommendations for continuing frequency of audits if facility has not achieved 100% compliance at the end of ninety days. The DON will receive a copy of the running monthly audit in order to supervise timeliness of the information to the residents. DON is responsible for this cprrection to be implemented.

FF11 483.21(b)(2)(i)-(iii):CARE PLAN TIMING AND REVISION

REGULATION: 483.21(b) Comprehensive Care Plans 483.21(b)(2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 16, 2018
Corrected date: December 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard survey completed on 10/16/18, the facility did not ensure that a comprehensive care plan must be prepared by an interdisciplinary team, that includes to the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident or their resident's representative is determined not practicable for the development of the resident's care plan for two (Resident #48 and #100) of four residents reviewed for care plan development. Specifically, residents did not participate in the care planning process. Additionally, lack of evidence that Resident #48 had an interdisciplinary care plan meeting. The finding is: Review of a policy entitled Interdisciplinary Care Plan revision date 2/2015 revealed each resident shall have a written care plan (CP). The plan shall be completed by the initial care plan conference and CP's must be pre-written before the scheduled care plan meeting, but the team members must discuss goals and methods of achieving those goals at the care plan meeting. 1. Resident #48 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 8/10/18 revealed that the resident was cognitively intact and was understood and usually understands. During an interview on 10/10/18 at 9:03 AM, Resident #48 stated, I have never met with nursing about my medications or have I been invited to a care plan meeting. I would go if I was invited. Review of the Progress Notes from 8/2/18 through 9/2/18 revealed there was no documented evidence the resident was invited to attend or that a care plan meeting was held. Review of the Social Services Progress Notes dated 8/2/17 through 9/2/18 revealed there was no documented evidence the resident was invited to attend their care plan meeting or reasons why they did not attend. In addition, there was no documented evidence that an interdisciplinary team care plan meeting was conducted. Review of a Comprehensive Care Plan identified as current, initiated on 8/3/18 revealed on page 17 a care plan attendance signature page. There were no signatures of those that attended or participated, the document was blank. During an interview on 10/12/18 at 1:53 PM, Social Worker (SW #1) stated she did not invite or have a care plan meeting for this resident. During an interview on 10/12/18 at 2:20 PM, the Director of Social Work (SW #2) stated she did not know if the resident was invited to participate in the care planning process, did not meet with the resident regarding her plan of care, and was unable to determine if an interdisciplinary care planning meeting was held for this resident. SW #2 further stated the social worker would document the interdisciplinary team meeting per the facility policy. During an interview on 10/15/18 at 11:38 AM, Registered Nurse (RN #1) stated she doesn't think an interdisciplinary team meeting was held for this resident and further stated there was no evidence a meeting was held. During an interview on 10/15/18 at 12:27 PM, MDS Coordinator Licensed Practical Nurse (LPN #2) stated the resident was admitted on [DATE], and the meeting was scheduled for 8/16/18. She further stated that she was unable to locate an attendance record/ signature sheet for the meeting and she was unable to find any information verifying that a meeting occurred. 2. Resident #100 was admitted into the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident was cognitively intact and was understood and understands. Review of the Social Work Progress Notes from 7/19/18 through 10/12/18 revealed there was no documentation the resident or family were invited or participated in the care plan process or to the care plan meeting held on 8/8/18. Review of the Care Plan Attendance Sheet for 8/8/18 revealed there were no signature that the resident or a resident representative attended. During an interview on 10/10/18 at 8:32 AM, Resident #100 stated, I have never been invited to a care plan meeting. I would go if I was invited. During an interview on 10/12/18 at 10:01 AM, Social Worker #1 stated, We send the letters to the families and if the resident has capacity we invite them to their care plan meetings. If the resident comes or declines it would be written in our progress notes. I do not see that she was invited, but she is not my resident as I am not the Social Worker for the rehab unit. During an interview won 10/12/18 at 10:03 AM, the Director of Social Work (SW#2) stated, I started in August. I cannot find a letter that we would have been sent out to the family inviting them to the. I was not here when the care plan meeting took place, so no I did not invite her. 415.11(c)(2)(ii)

Plan of Correction: ApprovedNovember 26, 2018

1. Resident # 48, and #100 will be re-invited to a care plan meeting within 30 days. An attendance sheet will be documented all those in attendance.
2. The facility policy on care plan attendance will be reviewed and updated as needed. All residents not having a scheduled care plan meeting within the next 45 days will have a care plan meeting. The SS department will document who is invited and who attendances each care conference moving forward in PCC.
3. Care plan invitations will be generated and mailed to the resident and/or designated HCP by the Receptionist as directed by the SW. A copy of the invitation will be maintained in the medical record under care plan by the SW for each resident invited. The attendance of the resident at the actual care planning conference will be recorded and noted in the medical record by SS for each care conference. The Director of SS will monitor this activity for compliance. SS will maintain a monthly list of those invited and those attended on a monthly audit tool.
4. SS will present the information of the monthly running audit at the facility QA meeting noting who invited and who attended and the total number of care plan conferences scheduled each month. The monthly audit will be maintained monthly times three months. If 100% compliance is achieved, the QA committee will recommend reducing or eliminating the monthly audit. 100% compliance will demonstrate the system created is working. The DON will supervise this plan.

FF11 483.90(d)(2):ESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION

REGULATION: 483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 16, 2018
Corrected date: December 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the Standard survey completed on 10/16/18, the facility did not maintain all essential mechanical, electrical and patient care equipment in safe operating condition. Issues included, sewer plumbing was leaking sewage into the building, open sewer plumbing, shower plumbing devices and hoses that did not have vacuum breakers to prevent backflow, and plumbing pipes were leaking water into the building. This affected three (Unit 1-2), Unit 5 and Unit 6) of three resident units, one (First Floor) of one resident use floor, one of one Second Floor (administration), and one of one Basement. The findings include but are not limited to: 1. a) Observation of the Basement's Center Core, near the Center stairway, on 10/9/18 at 12:20 PM, revealed the area smelled of sewage. Observation on the Basement's A Wing, on 10/9/18 at approximately 12:25 PM, revealed storage room A11 had a putrid, sour, sewage like odor eminating form inside. Further observations revealed a four-foot long horizontal section of the building's ten-inch wide main sewer pipe was observed at the bottom of a four-foot long by four-foot wide by five-foot deep pit. The pit had a one foot deep, gray colored, stagnant standing water with black and brown colored debris floating in it. Continued observations revealed the top of the main sewer pipe was approximately ten-inches wide, open, uncapped and sewage was observed to be running through the pipe. This ten-inch pipe was the clean-out (an entry point into a plumbing pipe/ drainage system so clogs can be removed) for the sewer pipe. On the floor of the room surronding the pit, was a two-foot long by one-foot wide by three-inch thick pile of black, brown, tan, and white colored debris. A submersible sump pump and an eight-foot long piece of flexible plastic pipe was also on the floor of the room near the pit. A three-inch open unsealed drain line was also observed near the pit. During an interview at the time of the observation, the Maintenance Director stated, he was not aware the pit was in this room or that the building's main sewer line and three-inch drain line were open and unsealed. b) Observation in the Basement on the B Wing, on 10/9/18 at approximately 1:10 PM, revealed the housekeeping storage room had a putrid, sour, and sewage like odor. Further observation, at this time, revealed a four-inch wide sewer pipe was open and uncapped with a six-foot long piece of flexible plastic pipe sticking out of it. Continued observations revealed a six-foot long by six- foot wide section of the floor, around this pipe, was covered with a half-inch deep layer of standing water with black debris floating in it, with a sewage like odor eminating from it. The observation also revealed water was intermittently pouring out of a sewer pipe that was installed through the ceiling of this room. During the observation the Maintenance Director stated, he was not aware the sewer pipe was open and uncapped or that the sewer pipe installed through the ceiling of the room was leaking. The Maintenance Director further stated that he believed a toilet was located on the First Floor, directly above this room, that was connected to the sewer pipe that was leaking into the housekeeping storage room. During the observation the Housekeeping and Laundry Director stated that the sewer pipe installed through the ceiling of the room had been leaking into the B-Wing housekeeping storage room for the least two weeks. c) Observation in the Basement, on the C Wing, on 10/9/18 at 1:46 PM, revealed the laundry storage room C14 smelled of sewage. Further observation revealed 20 cardboard boxes containing privacy curtains were stored in this room. d) Observation on the C Wing of the Basement, on 10/12/18 at 7:41 AM, revealed soiled water, with black debris floating in it was flowing out from under the corridor door of laundry storage room C 14. Further observation revealed an eight-foot long by three-foot wide area of the C Wing corridor was covered with a sewage smelling water, with black debris floating in it. Continued observation at this water was flowing into the stairway located near storage room C14. e) Observation on 10/15/18, between at 7:30 AM and 7:40 AM, revealed the first floor lobby, the area of the lobby near the Center Stairway door, the elevator lobby, the interior of the center stairway, the Second floor Center core, the Second Floor Conference room and the Center core of the Basement smelled of sewage. f) Observation at the exterior of the building on 10/15/18 at 8:05 AM revealed a six- inch long by one-foot wide area, at the loading dock, that was covered with a black-colored wet substance that was oozing out of the foundation wall of the building. This subastance had a sewage like smell. The black-colored substance had formed a six-foot long by one-foot wide puddle in the parking lot, in front of the loading dock. Further observation at this time revealed the loading dock was located at the end of the C Wing in the Basement. Continued observation, at the exterior of the building, revealed sewage water, with black debris floating in it, was running out from under the exterior exit door of the stairway located near storage room C 14, onto the side walk located outside the stairway exit door. g) Observation on the C Wing of the Basement, on 10/15/18, at 8:13 AM, revealed a six-foot long by six-foot wide area of the floor of laundry storage room C 14 was covered with a one half-inch deep layer of sewage smelling standing water with black debris floating in it. Further observation at this time revealed the sewage smelling water was flowing up through a four-foot long by one half-inch wide crack in the concrete floor of the room. Continued observation at this time revealed cracks between the room's floor and walls were partially filled with tan colored [MEDICATION NAME] plastic expanding foam. The room contained 20 cardboard boxes containing privacy curtains that were stored in the room on a two-wheeled hand cart. During the observation, the Maintenance Director stated the sewage/water had flowed out of the room and run down a 60-foot-long section of the C Wing corridor and the water had seeped into the dietary dry goods storage room, the housekeeping supply room and the laundry supplies rooms. The Maintenance Director further stated he had been using a floor cleaning machine to clean up the water and sanitized the floors with bleach. Observation of the dietary dry goods storage room, the housekeeping supply room and the laundry supplies rooms on the C Wing of the Basement on 10/15/18 at 8:15 AM revealed six-inch long by three-inch wide areas of the rooms had one-quarter inch to one-half inch deep areas of pooled water inside the rooms. Items in the storage rooms were store on top of milk crates and racks at least six-inches above the floors surfaces and no items appeared damaged from the sewer water . During an interview on 10/15/18 at 3:05 PM, the Administrator stated he was aware of the sewage leaks in the building that had started a couple weeks ago. The building had other plumbing issues in the past that the facility had addressed previously but they were not to the extent that the current pluming issue. The Administrator also stated, the facility had a lot of other things going on and he had to priorities what got taken care of first. The Administrator also stated the facility had come along way and addressed many issues. 2. a) Observation on the First Floor, Unit 1-2, on 10/9/18 at 10:22 AM, revealed the shower and shower wand in the Resident Spa (shower room) located near Resident room [ROOM NUMBER] did not have a vacuum breaker. The shower had a shower wand attached to it by a hose that allowed the wand to lie flush with the shower floor. The length of the hose allowed the shower wand to be submerged, if the shower floor did not drain properly. During the observation, the Maintenance Director stated he was not aware the shower's plumbing did not have a vacuum breaker. b) Observation on the First Floor, Unit 5, on 10/9/18 at 11:10 AM, revealed two showers and two shower wands in the Resident Spa located near Resident room [ROOM NUMBER] did not have vacuum breakers. The showers had shower wands attached to them by hoses that allowed the wands to lie flush with the shower's floor. The length of the hoses allowed the shower wands to be submerged, if the showers' floors did not drain properly. During the observation, the Maintenance Director stated he was not aware the showers' plumbing did not have vacuum breakers. c) Observation on the First Floor, Unit 6, on 10/9/18 at 11:29 AM, revealed the hair washing sink and the shower wand attached to it in the Beauty Shop did not have vacuum breakers. Further observation at this time revealed the shower wand was lying in the sink next to the sink drain. During the observation, the Maintenance Director stated the sink and the its shower wand's plumbing did not have vacuum breakers. d) Observation on the exterior of the building, on 10/9/18 at 3:22 PM, revealed the hose and hose bib located near the loading dock did not have vacuum breakers. During the observation, the Maintenance Director stated he was not aware the hose and hose bib did not have vacuum breakers. 3) Observation in the Basement, on the C Wing, on 10/9/18 at 2:02 PM, revealed a 20-foot long by 10-foot wide section of the floor in the Boiler room was covered with a one half-inch deep layer of water. Further observation at this time revealed water was flowing out of at least two pipes, with water was flowing across the room's floor into a floor drain. Further observation at this time revealed white towels had been tied around areas of the pipes where the water was leaking out. During the observation, the Maintained Director stated the pipes that were leaking were part of the return loop for the building's domestic hot water system and the pipes had been leaking for two weeks. 415.29(d)(f)(4)

Plan of Correction: ApprovedNovember 26, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1a) The pit and surrounding area of storage room [ROOM NUMBER] in the basement A wing was cleaned. The ten inch wide main sewer pipe was capped properly. All debris was removed from the room that shouldn't have been in there.
b) The sewer pipe that was leaking in the B-wing housekeeping storage room was fixed/replaced. Outside professional contractor DV Brown came in to replace the existing old sewer pipe that had cracked over time. This pipe was replaced using a new sewer pipe that replaced the old one. This new pipe eliminated the use of the old pipe that caused the back-ups.
c) The facility sewer pipe problems were fixed. The basement storage room C14 was cleaned and no other sewer smell existed.
d) The facility sewer pipe problem was fixed. The soiled water in the corridor by storage room C14 was cleaned up.
e) The facility sewer pipe problem was fixed. There is no sewer smell the first floor lobby area anymore.
f) The facility sewer pipe problem was fixed. The soiled water by the exit door in the basement C-wing, the loading dock and outside area was cleaned up.
g) The facility sewer pipe problem was fixed. The Dietary, Laundry and Housekeeping storage rooms in the basement of C-wing were cleaned and sanitized properly.
2a) The shower wand on units 1 and 2 was fixed with an appropriate vacuum breaker. The wand was off the shower floor.
2b) The two shower wands in the Resident Spa by Resident room [ROOM NUMBER] were fixed with an appropriate vacuum breaker. The wands are off the shower floor.
2c)The hose and hose bib located near the loading dock were fixed with appropriate vacuum breakers.
3a) The leaking pipes in the boiler room were fixed. They were replaced using new pipes. All leaking pipes were replaced with new pipes. The pooled water was removed.
2. A facility audit of all major mechanical, plumbing, electrical and care equipment were audited for proper maintenance and operation. Any areas of concern identified were noted on the audit tool and corrected.
3. A facility policy will be developed to address any persistent issue unable to be corrected on a consistent basis by the Administrator. The policy will include contacting the regional operations director who is new to the company, but has been a resource to repair persistent issues. The Maintenance Director will monitor and alert the Administrator to any new issues that are unable to be corrected at the facility level. The Administrator will contact the Regional Operations Director for assistance in resolving plumbing, electrical or patient care equipment problems.
4. The Maintenance Director will present at the monthly QA meeting any unresolved system issue and report per the facility policy steps taken to correct the issue. The QA committee will make recommendations and or comments and the Administrator will supervise the correction of the identified issues.

FF11 483.70(e)(1)-(3):FACILITY ASSESSMENT

REGULATION: 483.70(e) Facility assessment. The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The facility assessment must address or include: 483.70(e)(1) The facility's resident population, including, but not limited to, (i) Both the number of residents and the facility's resident capacity; (ii) The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population; (iii) The staff competencies that are necessary to provide the level and types of care needed for the resident population; (iv) The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and (v) Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services. 483.70(e)(2) The facility's resources, including but not limited to, (i) All buildings and/or other physical structures and vehicles; (ii) Equipment (medical and non- medical); (iii) Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies; (iv) All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care; (v) Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and (vi) Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations. 483.70(e)(3) A facility-based and community-based risk assessment, utilizing an all-hazards approach.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 16, 2018
Corrected date: December 14, 2018

Citation Details

Based on interview and record review conducted during the Standard survey completed on 10/16/18, the facility did not ensure that a facility-wide assessment was conducted to thoroughly assess the needs of its residents and to determine the required resources to provide the care and services to its residents during its day- to-day operations. Specifically, but not limited to, evaluation of diseases, conditions, physical or cognitive status and acuity of its resident population; areas of services and care offered based on resident's needs; and facility resources needed to provide competent support and care to their resident population, special care and services offered based on the residents' needs, contracts or other agreements with third parties to provide services or equipment to the facility and health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations were addressed. The finding is: During an interview on 10/10/18 at 1:57 PM, the Administrator stated they do not have a completed facility assessment. On 10/11/18 the Administrator presented a copy of an undated Facility Assessment Tool. Review of the undated Facility Assessment Tool, revealed there was no documented evidence that a complete assessment of the resident population considering the types of diseases, condition, physical and cognitive disabilities, and overall acuity was done. Additionally, there was no documented evidence or incomplete information that other facility resources, including, special care and services offered based on the residents' needs, contracts or other agreements with third parties to provide services or equipment to the facility and health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations were addressed. During further interview on 10/15/18 at 3:05 PM, the Administrator stated he was aware of the new regulations for a facility assessment but he prioritized and wanted to focus on providing quality of care first. 483.73 (a)(1)

Plan of Correction: ApprovedNovember 26, 2018

1a) A Facility Wide Assessment was conducted to thoroughly assess the needs of its Residents. This Assessment will determine the required resources needed to provide the care and services to its Residents during day-to-day operations.

2. Each Department Director under the supervision of the Director of Nurses and Administrator will work collaboratively to identify complete resources needed and complete the facility assessment plan. The plan will include, but not be limited to assessment of the current population, types of diseases, condition, physical and cognitive disabilities, as well as acuity.

3. The facility assessment plan will be reviewed on a quarterly basis by the Administrator to evaluate the plans continued accuracy and relevancy of the current resident population. The review will include all department directors and their input. Any changes to the plan will be made and the plan updated after review with the Medical Director. The Administrator will monitor the timely completion of these reviews and the validity of the assessment plan.

4. On a quarterly or semi-annual basis the Administrator will review the facility assessment at the QA committee meeting. All comments and or recommendations will be noted in the QA minutes. The Director of Nurses will supervise the timely completion and update of this facility assessment plan. The Quality Assurance Consultant will be responsible for this corrective action to be implemented.

FF11 483.25(c)(1)-(3):INCREASE/PREVENT DECREASE IN ROM/MOBILITY

REGULATION: 483.25(c) Mobility. 483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and 483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. 483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 16, 2018
Corrected date: December 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview completed during the Standard survey completed 10/16/18, the facility did not ensure that a resident with limited range of motion receives appropriate treatment and equipment to prevent further decrease in range of motion. Specifically, one (Resident #83) of six residents reviewed for range of motion (ROM - normal range of motion of a joint) services was not provided with an air splint to his left hand as recommended by Occupational Therapy (OT). Additionally, the there was a lack of documented evidence to support range of motion services were provided. The finding is: The policy and procedure (P&P) entitled Splint dated 10/19/15 documented OT will determine the need of a splint for a resident. The therapist will monitor the splint as indicated to ensure proper fit and nursing, resident and family members as indicated will be instructed in wearing schedule, application of the splint and precautions. The P&P entitled Range of Motion (ROM) and Assistance with Activities of Daily Living (ADL's) dated 10/19/15 documented each resident will be screened to identify his/ her ROM and ADL status. Certified Nursing Aides (CNA's) are expected to assist with ADL's and ROM at all times in accordance with the care plan. CNA's are to document that ADL and ROM assistance has been provided prior to the end of the CNA's shift. 1. Resident #83 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 8/24/18 revealed the resident was understood, understands and was cognitively intact. The MDS documented the resident had functional limitations on both sides of his upper extremities. Review of an undated comprehensive care plan (identified as current) revealed the resident had an ADL selfcare performance deficit related to [MEDICAL CONDITION] disease with interventions to include left hand air carrot on at all times except for hygiene, ROM and at bedtime (HS). Review of the Closet Care Plan (guide used by staff to provide care) last updated on 9/26/18 revealed the resident was on a Restorative Nursing Program (RNP) to include Passive Range of Motion (PROM-exercises preformed on the resident by nursing staff) to his left upper extremity (LUE) three times a week and was to wear a left-hand air hand carrot on at all times except for hygiene, ROM, and HS. The OT- Therapist Progress and Discharge Summary dated 9/13/18 documented a discharge plan and instructions to include the resident was to receive AROM (active) to the RUE (right upper extremity), PROM to the LUE three times a week, and a left-hand air carrot on at all times except for hygiene, meals and at night time. During intermittent observations on 10/10/18, 10/11/18 and 10/12/18 between the hours of 8:00 AM to 11:00 AM revealed the resident was in bed per his preference, ADL's were completed by the CNA. The resident had no left-hand air carrot in place. During an interview on 10/11/18 at 10:18 AM, CNA #4 stated the CNA's were responsible for providing the residents with ROM, documenting the information in the RNP binder at the end of the shift, and for splint application. The interview also revealed Resident #83 was not on her assignment today and that an agency CNA had him today. During an interview on 10/11/18 at 12:20 PM, the resident stated he had not seen the air splint for his left hand in a long time. He stated that he probably only wore it a couple times when it first started a few weeks ago and no one puts it on anymore. The interview further revealed the last two fingers on his left hand are very stiff, the finger tips are touching his palm and he cannot move them independently. The resident also stated he had not received his ROM exercises in a long time as well. Review of a Program Flow Sheet dated (MONTH) (YEAR) revealed Resident #83 was on a RNP and was to receive PROM to his LUE five times a week. There was no documented evidence that PROM was provided to the resident. During an interview on 10/12/18 at 9:29 AM, the Registered Occupational Therapist (OTR) stated the resident has contractures of his left shoulder, elbow, wrist, and fingers. He receives PROM to LUE and AROM to RUE. The aides should be doing ROM, documenting it in RNP book at the nursing station and it should be documented each day he receives it. The resident was discharged from program about a month ago, and he was asking for a splint for his left hand because he felt his fingers were getting tight. He was issued an air carrot for his left hand and he should be wearing it daily except for meals, HS, and hygiene. The CNA's should be putting it on because he needs help. Additionally, she had not heard he was having any problems with it and she would follow up with him. During an interview on 10/12/18 at 9:50 AM, the Assistant Director of Nursing (ADON) stated the CNA's were responsible for providing ROM and applying splints. Splints should be applied per therapy recommendations, and ROM is to be documented on the sheets three to five times a week. If there are blanks, then it means it wasn't done. We use a lot of agency staff and it's hard to make sure their all documenting like they should be. 415.12(e)(2)

Plan of Correction: ApprovedNovember 26, 2018

1. Resident # 83 was re-evaluated and the therapy discharge plan was updated for ROM and the use of the splint.
2. The facility restorative policy and procedure for splints and ROM will be updated. All current residents designated as receiving these specified services will be re-evaluated and the plan of care updated.

3. All full and part-time nursing assistants will be re-educated with proficiencies completed as it relates to splint care and ROM services. A post-test will be given. All new employees will receive this same education and proficiency within thirty days of starting employment by the therapy director or designee. At the time of education and or proficiency all aides will review the documentation required and where to document. All full and part time will be re-educated to the necessity of ROM and splint care and the requirement of reviewing documentation prior to the end of their shift. The Therapy Director or designee will audit the documentation of these services every week times 8 weeks and then monthly times three months. The Therapy Director will monitor this plan.

4. The Therapy Director will present at the facility monthly QA meeting the results of her audits on a monthly basis and degree of compliance of those audits. Based on compliance, the QA committee will recommend and or comment if additional audits and or training is required. The Director of Nurses will supervise this plan. The PT Director will be responsible for this corrective action to be implemented.

ZT1N 415.19:INFECTION CONTROL

REGULATION: N/A

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 16, 2018
Corrected date: December 14, 2018

Citation Details

Based on interview and record review during the Standard Survey completed on 10/16/18, the facility did not adopt and implement a Legionella culture sampling and management plan for their potable water systems. This affected three (Unit 1-2, Unit 5, and Unit 6) of three resident units, one of one Second Floor (administration), and one of one Basement. The finding is: Review of the facility's Legionella Risk Assessment, with a completion date of (MONTH) (YEAR), revealed it contained no documentation for the adoption or implementation of a Legionella culture sampling and management plan for the building's potable water system Review of the facility's Legionnaires Disease Infection Control and Monitoring Policy dated (MONTH) (YEAR) revealed: When a case of Legionnaires Disease has been confirmed and identified as healthcare-associated: the facility will conduct water sampling from potential sources such as resident room faucets, shower rooms, and hot water tanks. The policy contained no documentation that a Legionella culture sampling and management plan had been implemented. During an interview on 10/11/18 at 2:02 PM, the Administrator stated the facility had not conducted any water sampling of the building's potable water system. During an interview on 10/15/18 at 3:05 PM, the Administrator stated he was aware of the Legionella regulations but the facility had a lot of other things going on and he had to prioritize what got taken care of first. The Administrator also stated the facility had come along way and had addressed many issues. 415.19 NYCRR Title 10: 4-2.4

Plan of Correction: ApprovedNovember 9, 2018

1a) A water sampling in two resident room faucet on each hall, each shower room on each unit, and the boilers will be completed and the results logged.
2. The Maintenance department will be educated to the facility Legionella culture sampling and management program. The RN Staff educator will educate the maintenance staff on the requirements and correct culturing. The RN Staff Educator will receive and maintain the culture reports.
3. Cultures will be obtained on a quarterly basis varying resident room faucets, each shower area and the boilers on a quarterly basis. The results of the cultures will be maintained by the RN Educator and reviewed by the DON. The DON will monitor the completion of the cultures and results of those cultures.
4. Each quarter, the results of the cultures will be reviewed at the facility QA meeting. A log of each culture each quarter will be maintained by the DON. Any corrective action required will be completed by the DON and DOH guidelines followed. The QA committee will make additional recommendations or comments to the policy and results of cultures. The DON to supervise this plan.

FF11 483.90(i)(4):MAINTAINS EFFECTIVE PEST CONTROL PROGRAM

REGULATION: 483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 16, 2018
Corrected date: December 14, 2018

Citation Details

Based on observation, interview, and record review during the Standard survey completed on 10/16/18, the facility did not maintain an effective pest control program so that the facility was free from insects. This affected one (First Floor) of one resident use floor and one of one Basement. The findings are: 1. a)During an interview on 10/9/18 at 1:22 PM, Resident #32 stated there are bugs in the shower room the resident further stated, they are fruit flies. Observations in the First floor, Unit 6 Resident Spa (shower room) on 10/11/18 at 3:44 PM, revealed 12 small flies were observed on the privacy curtain near the shower stall light switches. Further observation at this time revealed the flies started flying around the room when the surveyor moved the curtain. Observations in the First Floor, Unit 6 Resident Spa, on 10/12/18 at 12:33 PM, revealed one small fly was flying around the room while the Assistant Director of Nursing (ADON) was removing Resident #7's leg dressings. The ADON swatted at the fly twice during the treatment change and stated, they have flies but they were bad in the summer and I'll take 1 or 2 (flies) over what it was like then. b) Observation in the Basement, on the C Wing, on 10/9/18 at 1:44 PM, revealed numerous small flies were covering the interior walls of the stairway located near storage room C14. Further observation, at this time, revealed a one-foot long by one-foot wide area around the floor drain, in the stairway, was partially covered with gray tape. The tape was covering half of the floor drain's three-inch grate. Continued observations revealed this stairway served as an exit to the exterior of the building from the C Wing of the Basement and as the rear exit from the Kitchen that was located on the First Floor. During the observation, the Maintenance Director stated the walls of the stairway were covered with over 1000 flies. During an interview on 10/16/18 at 9:08 AM the Maintenance Director stated, he was not aware of any reports of flies being recorded on any of the building's extermination inspection records. During an interview on 10/15/18 at 3:05 PM the Administrator stated, he was not aware of any issues with flies within the building Review of an extermination report dated 8/17/18 revealed: Treated Basement level drain with foam for the control of drain flies. Review of extermination report dated 9/27/18 revealed: The interior inspection of the kitchen and the hallway off of the kitchen there is fly activity. I believe there is a plumbing issue which should be addressed. 415.29(j)(5)

Plan of Correction: ApprovedNovember 9, 2018

1a) Orkin Pest Control is our regularly scheduled pest control company. They were called in additional to address the flies in unit six shower room.
1b) Orkin Pest Control Company was called in to address the fly problem in the basement near storage room c14. The sewer pipe problem was fixed in this area.
2. The pest control company was contacted to complete a 100% inspection of the facility to identify any other areas needing to be treated. The Maintenance Director will attend the facility inspection with the pest control company. All areas identified will be noted on the work order. A copy of the final report will be given to the Administrator for his review.
3. All department directors will be re-educated to communicate any pest issues to the maintenance department as soon as identified. The Maintenance Director and Administrator will determine if the pest control company should be contacted immediately or addressed on the monthly facility visit. The Maintenance Director or designee will accompany the pest control company at each monthly visit to validate that all issues have been addressed and obtain documentation of actions taken on the visit. The Maintenance Director will monitor this plan and review all visits with the Administrator.
4. The Maintenance Director will report at each monthly facility QA meeting the findings of the pest control company after each visit. In addition, the QA committee will seek any communication from the QA committee about any unaddressed pest issues within the facility. This will be noted in the QA minutes. The Administrator will review all pest control visits made each monthg. The Administrator will monitor this plan.

FF11 483.15(c)(3)-(6)(8):NOTICE REQUIREMENTS BEFORE TRANSFER/DISCHARGE

REGULATION: 483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must- (i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. 483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when- (A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. 483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. 483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. 483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at 483.70(l).

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: October 16, 2018
Corrected date: December 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard survey completed on 10/16/18 the facility did not ensure that Office of the State Long Term Care Ombudsman was notified of the transfer/discharge of each discharged resident. This was evident for three (Residents #49, 85 and 98) of three residents reviewed for admission, transfer, discharge notice requirements. Specifically, the facility did not send a copy of the discharge notice to the Office of the State Long Term Care (LTC) Ombudsman. 1. Resident #49 was admitted into the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident was cognitively intact and was understood and understands. Review of a Transfer / Discharge Notification dated 9/19/18 revealed the resident was discharged to home. Review of the progress notes dated 5/12/18 through 9/1918 revealed there was no documented evidence that a copy of the discharge notice dated 9/19/18 was sent to the Office of the State Long-Term Care Ombudsman. During an interview on 10/15/18 at 9:45 AM, Social Worker #1 stated, I do not contact the Ombudsman when a resident is discharged or goes to the hospital. I am the Social Worker for long term care, not rehab. I need to read the new regulations, I guess. I did not know this is a requirement. During an interview on 10/15/18 at 9:45 AM, the Director of Social Work stated, I have only been here since (MONTH) and have been gone the past two weeks. I do not know how they were doing this prior to me starting. Since I have been here I have not been sending notifications to the Ombudsman. I need to get in contact with the new Ombudsman as to the way she wants it sent. I do not know if we have a policy for notifying the Ombudsman when a resident is admitted , discharged or transferred. During an interview on 10/15/18 at 9:57 AM, the Representative from the Ombudsman Office stated they have not received any notifications form this facility regarding the discharges notices. They further stated, It is not happening. 2. Resident #85 was admitted into the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident was severely cognitively impaired and was understood and understands. Review of the Physician orders [REDACTED]. Review of a Discharge Summary from the hospital dated 10/4/18 revealed resident was admitted on [DATE] with an upper GI (gastrointestinal) Bleed. Review of the progress notes dated 10/1/18 through 10/15/18 revealed there was no documented evidence that a copy of a discharge notice was sent to the Office of the State Long-Term Care Ombudsman. 3. Resident #98 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a resident assessment tool) dated 8/31/18 documented the resident was cognitively intact understands and was understood. Review of the nurse's Progress Note dated 7/28/18 revealed the resident was admitted to the hospital with [REDACTED]. Review of the MDS' accepted into the database included a Discharge Assessment, Return Anticipated dated 7/27/18. Review of a Transfer / Discharge Notification dated 7/30/18 revealed the resident was sent to the hospital on [DATE] and was addressed to the resident and the resident's son. Review of the progress notes dated 7/30/18 through 10/15/18 revealed there was no documented evidence that a copy of the discharge notice dated 7/30/18 was sent to the Office of the State Long-Term Care Ombudsman. During an interview on 10/15/18 at 9:45 AM Social Worker (SW #1), stated she did not contact the Ombudsman when the resident was discharged . SW #1 stated she didn't know that she was supposed to and needed to read the new regulation. During an interview on 10/15/18 at 9:45 AM, the Director of Social Work stated she has only worked at the facility since (MONTH) and she will need to contact the Ombudsman to discuss how she would like the transfer/ discharge information sent to the Office of the State Long-Term Care Ombudsman. 415.3(h)(1)(iii)(a-c)

Plan of Correction: ApprovedNovember 26, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. The Discharge notice for Resident # 49 for discharge date [DATE] was sent to the Ombudsmen. The transfer notice for resident # 85 for hospital transfer of Oct. 1, (YEAR) was sent to the Ombudsmen. The transfer notice for resident 98 for hospital transfer (MONTH) 28 was sent to the Ombudsman. The Office of Ombudsman was given a secure email linking all admissions/discharges and transfers out of the facility to alert them of all resident changes within the facility.
2. A 100% audit with a 30 day look back from 9/16/2018-10/16/2018 was completed to identify discharge and hospital transfers were completed and notices were sent to the Ombudsman. The Social Service Department was educated to the updated policy and procedure as well as the new form to be used for all discharges and transfers by the QA consultant and the Director of Nursing for ensuring all notifications are sent to the Ombudsman.
3. The facility policy and procedure for hospital and discharge to home were included in the facility policy to include notification of the Ombudsman. A monthly audit will be completed to include all types of discharges and specifically notification of the Ombudsman by the Social Services department in the Monthly QA meeting. The Director of SW will review weekly x 6 weeks any recent discharges or transfers with the Administrator. This audit will be completed monthly x three months and then be re-evaluated for continuation. SS Director will be responsible for ensuring this corrective action to be implemented. `
4. The above listed audits will be reviewed by the Administrator at the monthly QA meeting as monitored by the Administrator. The QA committee will make additional recommendations to type and frequency or continuation of the audits until 100% compliance is reached.

FF11 483.45(a)(b)(1)-(3):PHARMACY SRVCS/PROCEDURES/PHARMACIST/RECORDS

REGULATION: 483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in 483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. 483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. 483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who- 483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. 483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and 483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 16, 2018
Corrected date: December 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard survey completed on 10/16/2018, the facility did not provide pharmaceutical services, including procedures that assure accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident. Two (Residents #89 and 94) of eight residents reviewed for pharmaceutical services had issues involving the lack of accurate medication order transcription. Specifically, the correct dosage of an antianxiety medication (Resident #89) and the correct frequency of a narcotic pain medication (Resident #94) were not accurately transcribed onto the current set of physician orders. The findings are: Review of the provided policy and procedure entitled Transcribing Physician Orders dated revised 9/2007 and reviewed 10/18, documented that Physician telephone orders will be co-signed by the provider within 48 hours. Transcribe the verbal order to triplicate form in resident's chart, verify order was entered into name computer program. Verify routine 30 or 60-day orders prior to the physician's visit and before the physician signature. 1. Resident #89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated revealed the resident had severe cognitive impairment, rarely understands and was rarely understood. Review of a Physician's Telephone/ Verbal Order dated 9/21/18 revealed an order for [REDACTED]. Review of a physician's orders [REDACTED]. Review of the Medication Administration Record (MAR) dated 10/01/18 to 10/31/18 revealed the resident received [MEDICATION NAME] 10 mg orally three times daily for anxiety. During an interview with the Director of Nursing (DON) on 10/15/18 at 11:21 AM, the DON stated, when an order is changed, the nurse needs to review the orders in-between interval checks, the verbal order taken would be the standing order in the MAR (medication admission record). The nurses need to make sure they check the orders so they match up against the standing order in the MAR. The protocol is when the doctor writes the order we transcribe it in the MAR and fax it over to pharmacy. So that is why in this case that the patient was getting the right drug and dosage. When doing the 60-day interval check the nurse must make sure that the orders are the same in the MAR. If there are any changes, they need to be caught so that the correct order goes on the MAR. The nurse did pull the 60-day orders, but missed the [MEDICATION NAME] dosage change. The nurses should not only use the MAR but check all the orders taken in-between the 60-day interval so that when the doctor comes in they have the correct orders that are both reflected in the doctor's orders in the chart and the MAR. During an interview on 10/15/18 at 11:47 AM, Registered Nurse (RN #2) stated when an order is written by a provider, the nurse transcribes the order and faxes it to the pharmacy. When checking the 60-day interval medication orders, you first pull the new orders for the doctor, then the nurse will check that all the orders are current against the MAR and the physician orders [REDACTED]. After the nurse checks the orders to ensure they are correct, they are flagged and the doctor sees the resident and signs off on the orders. The MAR gets printed from pharmacy then put in the book on the medication cart. 2. Resident #94 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident was cognitively intact. Review of a Telephone Order dated 9/10/18 revealed an order for [REDACTED]. Review of the physician's orders [REDACTED]. Review of the Medication Administration Record dated 10/1/18 to 10/31/18 revealed the resident received [MEDICATION NAME] 10/ 325 mg (milligrams) scheduled every six hours from 10/1/18 to 10/12/18. During an interview on 10/12/18 at 1:15 PM, the RN #3 Unit Manager stated that she was the nurse who reviewed the orders signed by the provider on 10/10/18. The RN stated that the provider must have seen the resident on 9/10/18 for her readmission, signed the orders and changed the [MEDICATION NAME] order on a telephone order form. The RN stated she didn't see the telephone order dated 9/10/18 because it was filed behind the readmission orders [REDACTED]. The resident was supposed to be getting the [MEDICATION NAME] scheduled every six hours. During an interview on 10/16/18 at 8:48 AM, the DON stated interval orders need to be reviewed and any changes need to be put on the newest set of physician's orders [REDACTED]. 415.18(a)

Plan of Correction: ApprovedNovember 26, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. A clarifying order for [MEDICATION NAME] for resident # 89 was obtained. The [MEDICATION NAME] for Resident # 94 was reviewed with the physician and clarifying order was obtained.
2. A 100% audit of (MONTH) Mars to the physician orders [REDACTED]. All full and part-time licensed nurses will be re-educated by the RN educator on transcribing physician orders [REDACTED].
3. The Director of Nurses will review and update the existing facility policy on transcribing orders and developing a double check system to catch any irregularities. The Unit Manager will complete a random audit of two new orders on each hall each week and verify the accuracy of the transcription. The audit will reflect the orders reviewed and if any inconsistencies were identified. The audits will be reviewed by the Director of Nurses or designee for any trends that might need remedial education. The audits will be completed for twelve weeks and then re-evaluated for compliance. The DON to monitor this plan.
4. The DON will present a summary of the weekly findings at the monthly QA meeting. The QA committee will make comment and or recommendations based on compliancy rate for continued auditing. The DON will supervise the plan.

FF11 483.10(a)(1)(2)(b)(1)(2):RESIDENT RIGHTS/EXERCISE OF RIGHTS

REGULATION: 483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. 483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. 483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. 483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. 483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. 483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 16, 2018
Corrected date: December 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 10/16/18, the facility did not treat each resident with respect and dignity and care for each resident in a manner and in an environment, that promoted maintenance or enhancement of his or her quality of life for two (Resident #87 and #111) of two residents reviewed for dignity. Specifically, Resident #87's Broda (a specialized wheel chair) chair was visibly soiled and Resident #111's clothing was visibly soiled with food debris on multiple occasions for extended periods of time. The finding is: 1. Resident #111 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 9/6/18 revealed the resident had severe cognitive impairment. Review of the Closet Care Plan (guide used by staff to provide care) dated 7/13/18 revealed the resident was supervision after set up for eating. Review of the Occupational Therapy -Rehabilitation Screening dated 8/29/18 revealed the resident was supervision after set up for eating. During an observation on 10/10/18 at 10:43 AM, the resident was wearing a pink long sleeve shirt and matching pants. The resident had cream and light brown colored debris on her lap. During an observation on 10/12/18 at 9:16 AM, the resident was sitting in her Broda chair in the chapel (dining room) finishing her breakfast. The resident had no clothing protector in place, was using built up utensils and had eaten all her solid food. At 9:31 AM, the resident was sitting in her Broda chair on the unit near the nurse's station, wearing a purple shirt with several white/cream colored spots of debris near her abdomen. At 10:20 AM, the ADON (Assistant Director of Nursing) transported the resident from nurse's station area into the lounge. At 11:22 AM, the resident was in the lounge on the unit, with the same clothes on, the food debris looked dried. At 11:35 AM, the unit clerk transported the resident from the lounge to the chapel for lunch. Further observation on 10/12/18 at 1:28 PM revealed the resident was being transported back to unit by certified nurse aide (CNA #3). The ADON requested the CNA to change the resident's shirt and the food on her shirt was not acceptable. During an interview on 10/12/18 at 1:28 PM, the ADON stated the resident should be wearing clean clothes and the CNA should have made sure the resident was clean. During an interview on 10/12/18 at 1:45 PM, CNA #2 stated she didn't notice the resident's clothes were soiled after breakfast. 2. Resident #87 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of a MDS dated [DATE] revealed the resident had moderate cognitive impairments, and the resident required total assistance of two persons for transfers and locomotion (how the resident moves between locations on and off the unit. Review of a policy entitled Wheel Chair and Geri-chair Cleaning dated 1/1/2002 revealed all wheel chairs (w/c) and Geri-chairs will be powered washed monthly Monday through Friday and documentation of power-washed wheelchairs and Geri-chairs will be done by the housekeeping department. A calendar of September (YEAR) and October (YEAR) documented a schedule for cleaning wheel chairs seven days a week. Additionally, Resident #87's room was scheduled to be cleaned on a Tuesday and on a Saturday. During intermittent observations from 10/09/18 through 10/11/18 between 8:30 AM and 9:53 AM revealed the resident sitting in her wheel chair; the arm rests of the w/c were visibly soiled with dried brown and white debris. On 10/12/18 at 10:30 AM the resident's w/c was observed while the resident was in bed; the arm rests, inner aspect of the side panels, and the w/c cushion were soiled with brown and white debris. During an interview on 10/12/18 at 10:30 AM, Resident #87 stated she minded that her w/c chair and cushion were not clean and would like them to be cleaned. During an interview on 10/12/18 at 10:34 AM, CNA #3 stated the resident's w/c was dirty with food spillage on the seat cushion, inside panels and the arm rests. There was a w/c cleaning schedule the housekeeping and nursing staff were to follow, but a wheel chair can be washed at any time if it is dirty. During an interview on 10/12/18 at 10:46 AM, the ADON observed Resident #87's wheel chair and stated the resident's wheel chair was dirty and needed to be cleaned. The housekeeping department has a schedule to clean the chairs on a regular basis and the schedule is also kept at the nurses' station desk. On 10/12/18 at 10:49 AM the ADON was unable to locate the wheelchair schedule for Unit 5. During an interview on 10/12/18 at 11:13 AM, the Housekeeping Department Director stated there was a calander (schedule) provided to each unit of wheel chairs to be washed on a monthly basis. The nursing department follows the schedule, and places the wheel chairs to be washed by the elevator Monday through Friday. They do not track which wheel chairs were washed. The Housekeeping Department Director reviewed the w/c schedule posted for (MONTH) and October, and stated the calendars were not correct. The calendars indicated the chairs are washed seven days a week, but the chairs are only washed Monday through Friday. The Housekeeping Director was unable to determine if Resident #87's w/c had been washed as scheduled. During an interview on 10/15/18 at 1:24 PM, the Director of Nursing (DON) stated resident's wheel chairs should be cleaned as scheduled, and as needed for both dignity and infection control reasons. 415.5(a)

Plan of Correction: ApprovedNovember 20, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This facility treats each resident with respect and dignity and care for each resident in a manner and environment that promotes quality of care.
1. Resident #87 Broda chair and Resident #111 her clothing was removed and cleaned were cleaned.
2. A 100% audit was conducted on all wheel chairs and walkers to inspect for cleanliness. Any device noted to be unclean was noted and cleaned. An audit was completed on available clothing protectors within the facility. A par level was established and an order for [REDACTED].
3. The facility policy as to frequency of cleaning wheelchairs and walkers was updated by the Housekeeping Supervisor and housekeeping/direct care aides educated by the RN Educator. A new schedule was posted at each unit. The Administrator and Housekeeping Supervisor will maintain a master schedule to monitor its completion. The facility will include the initial of the charge nurse upon completion of cleaning on each units monthly schedule to validate that cleaning is occurring. The Staff Educator will complete a post-test after re-educating the aides to increase awareness about changing clothes if soiled in a timely manner after each meal. Any direct care staff not receiving 100% of the post-test will be re-educated about the importance and timeliness associated with clothing and meal service.
4. Random weekly audits after meal service will be conducted on the units and main dining room five days per week x two weeks and then weekly x two weeks and monthly times two months by the Unit Managers across all three meals. The results of the audits will be reviewed at the monthly QA meeting for additional recommendations and or comments by The RN Educator. Audits will continue until each unit is at 100% compliance for clean clothing after meals. The housekeeping supervisor will monitor on a weekly basis the cleaning of wheel chairs and walkers. The supervisor will report at the monthly QA the results of the monthly schedule compared to actual validated by the shift charge nurse by the Housekeeping Supervisor. The DON to supervise for compliance.

ZT1N 713-1:STANDARDS OF CONSTRUCTION FOR NEW EXISTING NH

REGULATION: N/A

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: October 16, 2018
Corrected date: December 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the Standard survey completed on 10/16/18, resident rooms did not meet New York State Standards for Nursing Home Construction Projects. Issues included, resident rooms had night lights that were not functioning. This affected one (first Floor) of one resident use floor. The findings are: 1. a) Observations on the First Floor, on Unit 1, on 10/11/18 at 12:08 PM, revealed the night light in Resident room [ROOM NUMBER] was not functioning. During the observation, the Maintenance Director stated the facility had no documentation for the inspection and testing of night lights located in Resident Rooms. b) Observations on the First Floor, on Unit 2, on 10/11/18 from 12:12 PM until 12:23 PM, revealed the following Resident Rooms had night lights that were not functioning: #202, 203, 207, 211, 212, and 213. c) Observations on the First Floor, on Unit 5, on 10/11/18 from 12:27 PM until 12:43 PM, revealed the following Resident Rooms had night lights that were not functioning: #506, 516, 519, 522, 530, and 535. d) Observations on the First Floor, on Unit 6, on 10/11/18 from 12:45 PM until 1:08 PM, revealed the following Resident Rooms had night lights that were not functioning: #604, 606, 607, 610, 612, 615, 633, 634, 635. 713-2.22(d)

Plan of Correction: ApprovedNovember 26, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1a) The night light in Resident room [ROOM NUMBER] was fixed.
1b) The night lights in rooms 202, 203, 207, 211, 212, and 213 were fixed.
1c) The night lights in rooms 506, 516, 519, 522, 530 and 535 were fixed.
1d)The night lights in rooms 604, 606, 607, 610, 612, 615, 633, 634 and 635 were fixed.
2. A 100% audit of all night lights in resident rooms was conducted. Any night light obstructed or not functioning was corrected. The Maintenance Department was in-serviced by the Quality Assurance Consultant on night light operations, repair procedure and newly established audits to be conducted and frequency of audits.
3. The Maintenance department will audit night lights on each resident care unit on a quarterly basis maintaining there operation. The audit will reflect the date of the audit, any areas of concern identified and when the concern was corrected. The Maintenance Director will review the results of each audit with the Administrator. The Maintenance Director will monitor this plan.
4. The Maintenance Director will present at the facility QA meeting each month the results of the monthly audit and monitor compliance of night lights functioning at all times. The QA committee will make recommendations and or comments as to the continuation of the monthly audits after six months of night light audits demonstrates 100% compliance. The Administrator to supervise.

Standard Life Safety Code Citations

K307 NFPA 101:CORRIDOR - DOORS

REGULATION: Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 16, 2018
Corrected date: December 14, 2018

Citation Details

Based on observation and interview during a Life Safety Code survey completed on 10/16/18, corridor doors were not properly maintained. Issues included corridor doors were not designed to resist the passage of smoke, were obstructed from closing, and could not be latched into its door frame. This affected three (Units 1-2, Unit 5, and Unit 6) of three resident units. The findings include but are not limited to: 1. a) Observations on the First Floor, Unit 5, revealed a trash receptacle was obstructing the closure of the corridor door to Resident Room #519, at the following times: 10/9/18 at 11:13 AM, 10/10/18 at 10:43 AM, 10/11/18 at 12:43 PM, and 10/12/18 at 7:34 AM. b) Observations on the First Floor, Unit 5, revealed a trash receptacle was obstructing the closure of the corridor door to Resident Room #532, at the following times: 10/9/18 at 11:23 AM and 10/10/18 at 11:02 AM, c) Observation on the First Floor, Unit 6, on 10/9/18 at 11:47 AM revealed a four-foot tall by one-foot wide water cooler was stored in front of an obstructing the dining room's corridor door from closing. During the observation, the Maintenance Director stated he was not aware the water cooler was blocking the door and the staff knew doors were not to be blocked from closing. d) Observations on the First Floor, Unit 5, revealed a wooden door chock was wedged between the corridor door and door frame of the Unit Manager's office, obstructing the door from closing. Further observation revealed the office was located near Resident Room's #503 and 506. 2. Observation on the First Floor, Unit 1-2, on 10/9/18 at 10:08 AM, revealed when the door to resident room #109 was closed, there was a 12-inch long by one-half inch wide gap between the top of the corridor door and its door frame. During the observation, the Maintenance Director stated he was not aware of the gap between the door and its frame. The Maintenance Director further stated the facility had no documentation for the inspection and testing of the building's corridor doors. 3. Observations on the First Floor, Unit 6, on 10/11/18 at 1:08 PM, revealed the corridor door to resident Room #607 could not be latched into its door frame. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.6.3, 19.3.6.3.1, 19.3.6.3.5, 19.3.6.3.10

Plan of Correction: ApprovedNovember 20, 2018

1a) The trash receptacle obstructing Resident room #519 corridor door from closing was moved to allow the door to close properly.
1b) The trash receptacle obstructing Resident room #532 corridor door from closing was moved to allow the door to close properly.
1c) The four foot tall by one foot wide water cooler in the unit six dining room was removed to allow the door to close properly.
1d) The wooden door chock that was wedged between the corridor door and door frame to the manager's office on unit five was removed.
2a) The 12 inch long by one-half inch wide gap on Resident room #109 was fixed .
3a) The corridor door to Resident room # 607 was fixed so it would latch properly.
2. A 100% audit of corridor doors was completed for proper latching, no obstruction preventing closing and gaps to not allow smoke penetration. All areas identified were corrected as noted on the audit. The Maintenance staff were re-educated by the Administrator proper door closure being maintained.
3. A 100% audit will be completed on one of three units each month to monitor obstructions, improper latching and no smoke penetrations for corridor doors. The Maintenance Director will monitor the staff after reviewing the audit findings to validate corrections were made. This audit will be on-going and the results of each audit will be reviewed with the Administrator.
4. The Maintenance Director will review the corridor audit at the monthly QA meeting for additional comments and or recommendations. The Administrator will supervise this plan of correction.

K307 NFPA 101:DOORS WITH SELF-CLOSING DEVICES

REGULATION: Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 16, 2018
Corrected date: December 14, 2018

Citation Details

Based on observation and interview during a Life Safety Code survey completed on 10/16/18, stairway doors and hazardous area doors were not properly maintained. Issues included, stairway doors and hazardous area doors were held open and obstructed from closing by devices that were not arranged to automatically close the door upon activation of the required manual fire alarm system, local smoke detectors, automatic sprinkler system, and loss of power. This affected one of one Second Floor (administration) and one of one Basement. The findings are: 1. Observations on the Second Floor, on 10/9/18 at 8:57 AM and 2:07 PM, revealed the Center Stairway exit door was in a fully open position. Further observations at these times revealed the door was hung up on the floor of the Second Floor landing located within the stairway. Further observations on 10/10/18 at 7:49 AM, 12:17 PM, 2:11 PM, 2:40 PM, and 3:00 PM, revealed this door was in a fully opened position and hung up on the floor landing. During an interview on 10/9/18 at 8:57 AM the Maintenance Director stated, the door was hung-up on the landing's floor and he was not aware the door was getting hung-up on the floor. 2. a) Observations in the Basement on the C Wing, on 10/9/18 at 1:50 PM and on 10/15/18 at 7:57 PM, revealed the corridor door to the grease-trap room was in a fully open position. Further observation at this time revealed the door was equipped with a self-closing device and a three-foot tall dresser was wedged against the door obstructing it from closing. Continued observation at this time revealed the room was greater than 50 square feet in size and was being used to store two floor cleaning machines, seven mop buckets, two housekeeping carts, and a six-foot tall metal rack containing floor buffing pads and two batteries for floor cleaning machines. During the observation, the Maintenance Director stated the grease trap had overflowed on 10/8/18 and the door should not have been blocked open by the dresser. b) Observation in the Basement on the C Wing on 10/10/18 at 7:53 AM revealed the corridor door to the grease-trap room was in a fully open position. Further observation at this time revealed the door was equipped with a self-closing device and a two-foot long by six-inch long sand bag was wedged against the door obstructing it from closing. 3. Observations on the Center Core of the Basement, on 10/15/18 at 10:14 AM and on 10/16/18 at 9:03 AM, revealed when the doors closed, there was a seven-foot long by one half-inch wide gap between the double corridor doors that separated the LaVerna room form the Basement corridor. Further observation at this time revealed a metal hasp that was installed on the left door of the LaVerna room (as one looked from the Basement corridor into the room) was obstructing the right door from closing into its doorframe. Continued observation at this time revealed the right corridor door was equipped with a self-closing device. During an interview on 10/16/18 at 9:03 AM the Maintenance Director stated, he was not aware the doors to the room were obstructed. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.2.2.2.7, 7.2.1.8.2

Plan of Correction: ApprovedNovember 20, 2018

1a) The center stairwell exit door on the second floor was fixed to close properly.
b) The corridor door to the grease trap room is required to have a self closing device on it. The wedge was removed that blocked the door from closing properly.
c) The sandbag was removed from the grease trap room that was also blocking the door from closing properly.
d) The LaVerna room door gap when closed was repaired. The metal clasp was removed and obstruction removed.
(2) A 100% audit was completed on all doors with self closure. Any area identified as obstructed or needing repair was corrected. The Maintenance staff were re-educated by the Administrator on the responsibility to maintain self closure operation of doors and maintaining those areas free of obstructions.
(3) A monthly audit will be completed by Maintenance Department on all self closing doors for operation and lack of obstruction. The Maintenance person will review findings with Administrator noting corrections completed.
(4) The Maintenance Director will review audit findings at the monthly QA meeting. Audits will be ongoing. Administrator to supervise.

K307 NFPA 101:EGRESS DOORS

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 16, 2018
Corrected date: December 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during a Life Safety Code survey completed on 10/16/18, exit doors equipped with delayed- egress locks were not properly maintained. Issues included, an exit door equipped with an electromagnetic delayed-egress locking mechanism did not have an audible alarm that sounded when the delayed- egress function was initiated and the door could not be opened per the written instructions on the sign installed on the door and an exit door equipped with an electromagnetic delayed-egress locking mechanism did not have a sign posted on the door giving instructions on how the door could be opened. This affected one (Unit 5) of three resident units. The findings are: 1. Observations on the First Floor, Unit 5, on 10/9/18 at 11:02 AM, revealed exit door #9, located near Resident room [ROOM NUMBER], was equipped with an electromagnetic delayed-egress locking mechanism. A sign posted on the door read as follows: Emergency exit only push until door alarm sounds door can be opened in 15 seconds. In order to test the delayed egress mechanism, the Maintenance Director pushed the door's crash bar assembly (device for unlocking a door during emergency condition) which was electronically connected to the door's electromagnetic delayed- egress locking mechanism. No audible alarm sounded at this time. The Maintenance Director reset the exit door's electromagnetic delayed- egress locking mechanism, pushed the door's crash bar assembly a second time, and no audible alarm sounded. The Maintenance Director reset the exit door's electromagnetic delayed- egress locking mechanism, pushed the door's crash bar assembly a third time, and no audible alarm sounded. The Maintenance Director pushed the door's crash bar assembly three additional times and each time the door's electromagnetic delayed- egress locking mechanism would not release the door and the door could not be opened. During the observations, the Maintenance Director stated the exit door was equipped with an electromagnetic delayed- egress lock and the facility had no documentation for the inspection and testing of the building's exit doors that were equipped with electromagnetic delayed- egress locks. 2. Observation on Unit 5, on 10/12/18 at 7:47 AM, revealed exit door #10, located in the Unit 5 dining room, was equipped with an electromagnetic delayed-egress mechanism. This exit door did not have a sign posted on the door, giving instructions on how the door could be opened. During the observation, the Maintenance Director stated he was not aware the door was equipped with a delayed-egress lock and he did not know why the door did not have a sign posted, giving instruction on how the door could be opened. Per the 2012 edition of National Fire Protection (NFPA) 101 Life Safety Code: A readily visible, durable sign on a contrasting background that reads as follows Push until alarm sounds door can be opened in 15 seconds shall be located on the door leaf adjacent to the release device in the direction of egress. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2102 NFPA 101:19.2.2.2.4, 7.2.1.6.1, 7.2.1.6.1.1(3)(c), 7.2.1.6.1.1(4)

Plan of Correction: ApprovedNovember 20, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1a) Exit door #9 located by Resident room [ROOM NUMBER] was equipped with an electromagnetic delayed egress mechanism. The mechanism was serviced to work properly. The audible alarm sounds now and the release works as designed.
b) A proper sign was placed by exit door #10 located in the dining room of unit 5. This sign gives instructions on how to open this door since it has an electromagnetic delayed egress mechanism on it.
(2) A 100% audit of all mag lock doors was conducted. Any areas of concern identified were corrected.
(3) The Maintenance staff will be educated by the Administrator on proper door operation for delayed egress, necessary signage required for delayed egress doors and monthly audits to maintain proper functioning and presence of signage. All mag lock doors will be audited monthly for proper operation and signage. Any area identified as needing attention will be noted on log by Maintenance staff and then repaired. The audit will be reviewed by Maintenance Director and Administrator monthly.
(4) The findings of the monthly audit and corrections will be reviewed at the monthly QA meeting by the Maintenance Director. The review will include items repaired. Administrator to supervise.

K307 NFPA 101:ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 16, 2018
Corrected date: December 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during a Life Safety Code survey completed on 10/16/18, electrical equipment was not properly maintained. Issues included: in-use power strips were daisy chained (refers to power strips and/or extension cords being plugged into other power strips and/or extension cords) to unapproved electrical adapters or other power strips, unapproved electrical adapters were in-use, an extension cord was in-use and run under a closed door, and an unapproved power strip was being used in a resident room. This affected one (Unit 6) of three resident units, one of one Chapel, one of one Second Floor (administration), and one of one Basement. The findings include but are not limited to: 1) a) Observation on the Second Floor, on 10/9/18 at 9:19 AM, revealed a power strip with a three-prong plug was daisy chained into a six-outlet electrical adapter with a two-prong plug that was supplying power to a computer and a printer in the Nursing Operations Manager's office. During the observation the Maintenance Director stated, he was not aware the power strip and adapter were plugged together and they should not have been plugged together. b) Observation in the Basement on the A Wing, on 10/9/18 at 12:40 PM, revealed a power strip was daisy chained to another power strip was supplying power to equipment for the building's computer and telephone systems in room A 4, the server room. 2) Observation on the First Floor, on 10/9/18, at 10:40 AM, revealed a six-outlet electrical adapter was supplying power to a fan and an organ in the Chapel. 3) Observation on the Center Core of the Basement, on 10/9/18 at 12:22 PM, revealed and extension cord that was supplying power to a floor cleaning machine was run under one of the double corridor doors (left door as one looked at the room from the Basement corridor) to the LaVerna storage room. During the observation the Maintenance Director stated the extension cord should not have been run under the door. 4) Observation on the First Floor on, on Unit 6, on 10/11/18 at 12:56 PM revealed an unapproved power strip was supplying power to a fan located in Resident room [ROOM NUMBER]. During the observation the Maintenance Director stated, he was not aware the power strip was being used in the room and the power strip was not approved to be used in the room. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 2.1, 2.2, 10.2.3.6, 10.2.4.1, 10.2.4.2, 10.2.4.2.1, 2011 NFPA 70: 110.3(A)(1), 110.3(A)(7), 110.3(A)(8), 400.3, 400.8(1), 400.8(3), 590.3(B)

Plan of Correction: ApprovedNovember 9, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1a) The six outlet electrical outlet was removed from the Nursing Operation's managers office on the second floor. All electrical equipment was plugged into approved UL devices.
b) The building's computer and telephone systems in the server room were plugged into a approved UL device and removed from the connecting daisy chain.
a) The six-outlet electrical adapter was replaced with approved UL rated device.
a) The extension cord that was run under the door to the LaVerna room was removed.
a) The unapproved power strip in Resident room [ROOM NUMBER] was removed and replaced with an approved UL rated device.
2. A 100% facility audit was completed to identify all extension cords present in resident rooms and common areas. Any issue identified with the audit was corrected.
3. A letter describing the acceptable extension cord will be placed in the admission paperwork to be completed at the time of admission. The Maintenance Director or his staff will audit one hall per month to ensure that extension cords are absent or appropriate that are in use. The Maintenance director will monitor this plan. The results of the audit will be reviewed with the Administrator.
4. The Maintenance Director will present at the monthly QA meeting the results of the extension cord audit each month. The audit will track number of extension cords found and of those found where they to code. The QA committee will make further recommendations and or comments. The audits will be on-going. The Administrator to supervise this plan.

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 16, 2018
Corrected date: December 14, 2018

Citation Details

Based on interview and record review during a Life Safety Code survey completed on 10/16/18, the facility did not have documentation of weekly inspections and monthly load tests for the emergency generator. This affected three (Unit 1-2, Unit 5 and Unit 6) of three resident units, one of one Second Floor (Administration) and one of one Basement. The findings are: A review of weekly generator logs on 10/11/18, revealed the logs contained no documentation of weekly inspection and monthly loads tests for the emergency generator from 1/25/17 through 5/30/17. A review of outside contractor's inspection forms on 10/11/18, revealed the building's emergency generator had been inspected on 2/27/18 and 6/15/18. During an interview on 10/11/18 at 2:16 PM, the Maintenance Director stated the facility had no documentation that verified weekly inspections and monthly load tests had been conducted on the building's emergency generator during the last 12 months. 10 NYCRR 415.29(a)(2), 711.2(a)(1) NFPA 110: 8.4.1, 8.4.2

Plan of Correction: ApprovedNovember 9, 2018

1a) Weekly inspections and monthly test loads of the generator are now being conducted and documented properly.
2. The Maintenance Director will contact the preventative maintenance generator company and schedule weekly inspections and monthly full load test education. The Maintenance Director will develop a monthly audit tool to document the weekly and full loads tests.
3. The Maintenance Director and or staff will complete and log the weekly and monthly generator tests. The Maintenance Director will review monthly with the Administrator the results of the monthly activity. The Maintenance Director will add to the Master Calendar the required tests. The Maintenance Director to monitor for compliance.
4. The Maintenance Director will review at each monthly QA meeting the results of the weekly run and full load test on a monthly basis. The QA committee will comment and or make recommendations. The audit will be on-going.
The Maintenance Director will maintain the monthly generator activities in a maintenance preventative activities within his department. The Administrator to supervise this plan.

K307 NFPA 101:ELECTRICAL SYSTEMS - OTHER

REGULATION: Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 6 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 16, 2018
Corrected date: December 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during a Life Safety Code survey completed on 10/16/18, electrical systems were not properly maintained. Issues included, electrical outlets and electrical junction boxes were missing their cover plates. This affected two (Unit 1-2 and Unit 5) of three resident use floors, one of one Second Floor (administration) and one of one Basement. The findings include but are not limited to: 1. a) Observation on the Second Floor, on 10/9/18 at 9:04 AM, revealed the cover was missing from a four-plex electrical outlet in the Social Work office. Further observations revealed a fan, a computer, a computer monitor, and a telephone charger were plugged into the outlet's receptacles. During an interview at the time of the observation, the Maintenance Director stated he was not aware the outlet was missing its cover. b) Observation in the Basement on the A Wing, on 10/9/18 at approximately 12:25 PM, revealed a duplex electrical outlet located in storage room A11 was missing its cover. c) Observation on the First Floor, on Unit 1-2, on 10/12/18 at approximately 12:17 PM, revealed a duplex electrical outlet located in Resident room [ROOM NUMBER] was missing its cover. Further observations revealed a telephone charging cord was plugged into the top receptacle of the outlet. During the observation, the Maintenance Director stated he was not aware the outlet was missing its cover. 2. a) Observation above the First Floor corridor ceiling tiles on Unit 1-2, on 10/10/18 at 9:36 AM, revealed an electrical junction box, located near the cross corridor convenience door at the entrance to the Unit 1-2, near exit door #3, was missing its cover. During the observation, the Maintenance Director stated he was not aware the junction box was missing its cover. b) Observation above the First Floor corridor ceiling tiles on Unit 1-2, on 10/10/18 at 10:13 AM, revealed an electrical junction box located near the stairway exit door by Resident Rooms #212 and 213 was missing its cover. During the observation the Maintenance Director stated, he was not aware the junction box was missing its cover. c) Observation above the First Floor ceiling tiles, on Unit 5 on 10/10/18 at 10:50 AM, revealed an electrical junction box located in Resident room [ROOM NUMBER] was missing its cover. d) Observation above the First Floor corridor ceiling tiles, on Unit 5 on 10/10/18 at 11:00 AM, revealed an electrical junction box located above stairway exit door # 11, by Resident Rooms #535 and 536, was missing its cover. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 6.1, 6.1.1, 1.3, 1.3.2.1, 6.3.2, 6.3.2.1, 2011 NFPA 70: 110.3(A)(1), 110.3 (A)(8), 314.25, 314.72(C)

Plan of Correction: ApprovedNovember 9, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1a) The cover for the four-plex electrical outlet in the Social Work office was replaced.
b) The cover to the duplex electrical outlet located in storage room [ROOM NUMBER] was replaced.
c) The cover for the duplex electrical outlet in Resident room [ROOM NUMBER] was replaced.
d) The cover for the electrical junction box located near exit door #3 was replaced.
e) The cover for the electrical junction box located near the stairway exit door by Resident room [ROOM NUMBER] and #213 was replaced.
f) The cover to the electrical junction box located in Resident room [ROOM NUMBER] was replaced.
g) The cover to the electrical junction box located above stairway exit door #11 by Resident rooms #535 and #536 was replaced.
2. A 100% facility audit was completed to identify any other missing or broken electrical plates. Any areas identified will be repaired and noted on the audit tool.
3. Each month, one of three units will be audited to maintain electrical plates. Any electrical plate broken will be noted on the audit by the maintenance staff and corrected. The monthly audit will be reviewed by the Maintenance Director with the Administrator. This audit will be on-going. The Maintenance Director will monitor.
4. The Maintenance Director will present at the monthly QA meeting the findings of the audit and number of corrections made. The QA committee will comment and or make recommendations. The Administrator will supervise this plan.

K307 NFPA 101:ELEVATORS

REGULATION: Elevators 2012 EXISTING Elevators comply with the provision of 9.4. Elevators are inspected and tested as specified in ASME A17.1, Safety Code for Elevators and Escalators. Firefighter's Service is operated monthly with a written record. Existing elevators conform to ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators. All existing elevators, having a travel distance of 25 feet or more above or below the level that best serves the needs of emergency personnel for firefighting purposes, conform with Firefighter's Service Requirements of ASME/ANSI A17.3. (Includes firefighter's service Phase I key recall and smoke detector automatic recall, firefighter's service Phase II emergency in-car key operation, machine room smoke detectors, and elevator lobby smoke detectors.) 19.5.3, 9.4.2, 9.4.3

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 16, 2018
Corrected date: December 14, 2018

Citation Details

Based on interview and record review during a Life Safety Code survey completed 10/16/18, the building's elevator was not properly maintained. Issues included: the in-car bell alarm was not operational, no-load safety testing was due, the five-year, full load, rated speed safety test was overdue, and the bottom run by of cars and counterweights needed ropes to be shortened and then retested . This affected one of one elevator. The findings are: 1. During an interview on 10/16/18 at 9:08 AM, the Maintenance Director stated the facility did not have a copy of the 1/2/18 inspection and test report of the building's elevator. The Maintenance Director further stated, the facility had no documentation that any of the elevator's outstanding deficiencies had been corrected and none of the elevator's outstanding deficiencies were corrected. Record review of an elevator inspection and test report dated 9/18/19 revealed: - The following old repeat violations shall be addressed. - the in-car alarm bell was not operational (originally cited on 1/2/18) - no-load safety testing was due (originally cited on 1/2/18) - five-year, full load, rated speed safety test was overdue (originally cited on 1/2/18) - the bottom run by of cars and counterweights needed ropes to be shortened and then retested . (originally cited on 2/28/17) Record review of an elevator inspection and test report dated 2/28/17 revealed: - Unsatisfactory testing was conducted and the following issues shall be addressed before test can be classified as satisfactory. - the bottom run by of cars and counterweights needed ropes to be shortened and then retested . - a metal capacity plate shall be installed in a conspicuous place inside the car and shall indicate the rated load in letters and numerals not less than 0.25 inches high, stamped, etched, or raised on the surface of the plate. - a proper pit access ladder shall be provided. During an interview on 10/15/18 the Administrator stated, he was not aware the elevator had outstanding deficiencies that had not been corrected. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.5.3, 9.4.2.2, 9.4.2.3

Plan of Correction: ApprovedNovember 9, 2018

1a)An outside elevator repair company will be brought in to inspect and fix the identified issues with the elevator. The following will be addressed
- install the capacity plate at least .25 inches high
- install a pit access ladder
-fix in-car alarm bell
-no-load safety testing completed
-five year, full load, rated speed safety test completed
-The bottom run by of cars and counterweights ropes will be shortened and retested -
-a metal capacity plate will be installed in a conspicuous place inside the car and will indicate the rated load in letters and numerals less than 0.25 inches high, stamped, etched or raised on the surface of the plate
2. The Maintenance Department will be educated to the proper maintenance required by life safety for elevators.
3. The Maintenance department will check on a monthly basis the following as it relates to the elevator: proper operation of the in-car bell alarm, and visual observation of the bottom run of car is functioning. In addition the Maintenance Director will schedule the following inspections with an outside vendor: no load safety testing, the five year full load rated speed safety test and adjustment and retesting of the ropes. The Maintenance Director will then add the necessary inspections to the master calendar so as to maintain inspections as required by code. The Maintenance Director will monitor this plan.
4. The Maintenance Director will present at the monthly QA meeting for additional comments and or recommendations the results of the above listed inspections and level of compliance. At this time he will also distribute the Master calendar with the necessary outside vendor inspections. The administrator to supervise this plan.

K307 NFPA 101:EXIT SIGNAGE

REGULATION: Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 16, 2018
Corrected date: December 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the Life Safety Code survey completed on 10/16/18, exit signs were not properly maintained. Issues included, exit signs: were not illuminated, did not show the proper direction of egress, or were missing from exit egress corridors. This affected two (Unit 1-2 and Unit 5) of three resident units one of one Basement, and one of one Second Floor (administration). The findings are: 1. a) Observation on the Second Floor, on 10/9/18 at 8:44 AM, revealed the exit sign located above the Center stairway exit door, near the Minimum Data Set (MDS) Coordinator's office, was not illuminated. During an interview on 10/9/18 at 8:54 AM, the Maintenance Director stated the exit signs on the Second Floor had not been illuminated for two weeks and he was trying to figure out which electrical panel and wiring supplied the power to the signs. b) Observation on the Second Floor, on 10/9/18 at 9:22 AM, revealed the exit sign located above the stairway exit door near the Nursing Operations Manager's office was not illuminated. c) Observation in the Basement, on the C Wing, on 10/9/18 at approximately 1:42 PM revealed the exit sign, located above the exit door between the loading dock and storage rooms C13 and C14, was not illuminated. Further observation revealed the exit sign was located above the exit door of the stairway that served the C Wing of the Basement and the rear of the Kitchen on the First Floor. During the observation, the Maintenance Director stated he was not aware the exit sigh was not illuminated. d) Observation in the Basement on the C Wing, on 10/9/18 at 2:02 PM, revealed an exit sign located above the Boiler room exit door, was not illuminated. During the observation, the Maintenance Director stated he was not aware the exit sigh was not illuminated. 2) Observation on the First Floor, Unit 1-2, on 10/9/18 at 10:02 AM, revealed the chevron (directional arrow) on the illuminated exit sign installed near Resident room [ROOM NUMBER], directed the path of egress into Resident room [ROOM NUMBER]. Further observation revealed there was no path of egress to the exterior of the building through Resident room [ROOM NUMBER]. During the observation, the Maintenance Director stated the arrow on the exit sign showed the path of egress was into Resident room [ROOM NUMBER]. 3. a) Observation on the First Floor, Unit 1-2, on 10/9/18 at 10:19 AM, revealed an exit sign was not installed above the corridor smoke barrier doors near Resident room [ROOM NUMBER] and 203. During this observation, the Maintenance Director stated he did not know why an exit sign was not installed above the doors. c) Observation on the First Floor, Unit 5, on 10/10/18 at 10:40 AM, revealed an exit sign was not installed above the corridor smoke barrier doors near the double corridor doors to the Therapy room. During the observation, the Maintenance Director stated he did not know why an exit sign had not been installed above the doors. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.2.10.1, 7.10, 7.10.1.2.1, 7.10.1.2.2

Plan of Correction: ApprovedNovember 9, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1a&b) All illuminated exit signs on the second floor have been fixed and illuminate properly.
c) The exit sign located above the exit door between the loading dock and storage rooms c13 and c14 was fixed to illuminate properly.
d) The exit sign located above the boiler room exit door was fixed to illuminate properly.
e) The illuminated exit sign installed near Resident room [ROOM NUMBER] was adjusted to direct the path of egress to the exit door.
f) An illuminate exit sign was installed near Resident rooms #202 and #203.
g) An illuminate exit sign was installed above the corridor doors to the Therapy Room.
(2) A 100 % audit of all exit signs for illumination and direction was completed.
(3) A monthly audit will be completed to ensure all exit signs illuminate. Any non illuminating signs will be repaired by Maintenance Department. Maintenance Director to monitor.
(4) Audits will be ongoing. Audit finding will be reviewed at the monthly QA meeting. Administrator to supervise.

K307 NFPA 101:FIRE ALARM SYSTEM - TESTING AND MAINTENANCE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 16, 2018
Corrected date: December 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during a Life Safety Code survey completed on 10/16/18, the automatic fire alarm system was not properly maintained. Issues included: an audible device that failed its testing was not repaired or replaced, and smoke detectors that failed their sensitivity testing were not repaired, replaced, or retested . This affected three (Unit 1-2, Unit 5, and Unit 6) of three resident units, one of one Second Floor (administration) and one of one Basement. The findings are: 1. Review of an outside contractor's fire alarm system inspection report dated 6/9/18, revealed the horn (audible fire alarm device) located in the corridor on Unit 5 near Resident room [ROOM NUMBER] did not function properly and needed to be replaced. During an interview on 10/16/18 at 9:09 AM the Maintenance Director stated, he believed the horn that was marked as not functioning on the fire alarm inspection record from (MONTH) of (YEAR) had been repaired but the facility did not have documentation to verify it had been repaired. During an interview on 10/16/18 at 9:10 AM the Maintenance Director stated the last time sensitivity testing had been conducted on the building's smoke detectors was in (YEAR) and the only documentation the facility had for the replacement or sensitivity testing of the building's smoke detectors was a sensitivity testing report dated 5/9/16 and a service order dated 7/6/16. 2. Review of an outside contractor's fire alarm sensitivity testing report dated 5/9/16, revealed six smoke detectors failed their sensitivity testing and one smoke detector had a sensitivity reading of zero, but was not listed as failed on the report. During an interview on 10/16/18 at 9:10 AM, the Maintenance Director stated the last time sensitivity testing had been conducted on the building's smoke detectors was in (YEAR) and the only documentation the facility had for the replacement or sensitivity testing of the building's smoke detectors was a sensitivity testing report dated 5/9/16 and a service order dated 7/6/16. Review of the outside contractor's service order dated 7/6/16, revealed two of the six smoke detectors that failed their sensitivity testing from the 5/9/16 report were replaced but not retested and the report had no documentation about the smoke detector that had a reading of zero. Per the 2010 edition of NFPA 72, National Fire Alarm and Signaling Code: smoke detectors sensitivity testing shall be checked within one year after installation and sensitivity shall be checked every alternate year thereafter. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 9.6.1.3 2010 NFPA 72: 14.4.5.3.1, 14.4.5.3.2

Plan of Correction: ApprovedNovember 9, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1a) The horn located in the Unit 5 Corridor near room [ROOM NUMBER] was re-inspected to validate the repair was completed previously. The six smoke detectors identified in the (MONTH) (YEAR) sensitivity test was reinspected to validate it was functioning.
2. A complete sensitivity test will be completed for the entire facility. Any areas identified by the testing will be identified and repaired by the vendor and documented.
3. The Maintenance Director will review all sensitivity test findings with the Administrator to identify that all areas identified as needing attention have been captured, corrected and documented ass corrected. In addition, The Maintenance Director will develop a main calendar to required testing and schedule identified testing at least six months prior to the date due. The Maintenance Director will maintain the master calendar and copy it to the Administrator. The Maintenance Director to monitor.
4.The Maintenance Director and/or Administrator will review the findings and correction of the sensitivity test at the monthly QA meeting for additional comments and or recommendations. Any life safety requirements similar in nature will be reviewed at the QA meeting noting compliance with requirement, timeliness of testing and corrections made in a timely manner. The Administrator to supervise this activity.

K307 NFPA 101:FIRE DRILLS

REGULATION: Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 16, 2018
Corrected date: December 14, 2018

Citation Details

Based on interview and record review during the Life Safety Code survey completed on 10/16/18, fire drill records were not properly maintained. Issues included, the facility did not have documentation that verified fire drills had been conducted at least quarterly on each shift. This affected three (Unit 1-2, Unit 5, and Unit 6) of three resident units, one of one Second Floor (administration) and one of one Basement. The findings are: Review of fire drill reports on 10/10/18 revealed the facility had no documentation fire drills had been conducted: on the First and Third Shifts in the Third Quarter (July, August, September) of (YEAR), on the Third Shift in the Fourth Quarter (October, November, December) of (YEAR), on the First, Second, and Third Shifts of the First Quarter (January, February, March) of (YEAR), and on the First, Second, and Third Shifts of the Third Quarter (July, August, September) of (YEAR). During an interview on 10/10/18 at 2:17 PM the Maintenance Director state, the facility had no documentation for the fire drills that were missing from (YEAR) and (YEAR). During an interview on 10/15/18 at 3:05 PM the Administrator stated, he became aware that documentation for fire drills was missing in (MONTH) of (YEAR) and the facility conducted a fire safety in-service on 4/25/18 to make sure all staff had fire drill training. The Administrator further stated he knew fire drills were being conducted because they were conducted when he was in the facility. Review of a Fire Safety in-service sign-in sheet revealed the facility's staff had been in-serviced on fire safety on 4/25/18. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.7.1.6

Plan of Correction: ApprovedNovember 9, 2018

1a) A fire drill on each shift will be conducted in (MONTH) and documented. Education after each drill will be provided and documented as to who participated and who received education. Each practice drill will be evaluated.
2. The Maintenance department will be educated as to scheduling and completing fire drills according to the regulation and a post-test provided. The facility staff will be re-educated to performance and accountabilities at a fire drill by the RN Educator. A post-test will be completed by all educated.
3. The Maintenance Director will complete a master calendar for the fire drills for the year and a copy provided to the Administrator. The Maintenance Director will educate the Administrator and maintenance staff as to how to conduct the drill so the drills go off as scheduled with or without the Maintenance Director. A wrtitten copy of the drill evaluation will be given to the Administrator for his review. The performance of the staff at each drill will be evaluated and remedial education by the RN educator will be provided as indicated by the evaluations. The Maintenance Director to monitor.
4. The Maintenance Director at each monthly QA meeting will review the fire drills to include the evaluations of staff. The QA committee will make additional comments and or recommendations. The QA committee will determine if additional drills need to take place based on evaluation and staff performance. The Administrator to supervise this plan.

K307 NFPA 101:FUNDAMENTALS - BUILDING SYSTEM CATEGORIES

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 16, 2018
Corrected date: December 14, 2018

Citation Details

Based on interview and record review during a Life Safety Code survey completed on 10/15/18, a risk assessment was not conducted on the building's systems. Issues included, the facility did not conduct a defined and documented risk assessment for the building system categories in accordance with National Fire Protection Association (NFPA) 99 - Health Care Facilities Code. This affected three (Unit 1-2, Unit 5 and Unit 6) of three resident units, one of one Second Floor (administration) and one of one Basement. The finding is: 1. During an interview on 10/11/18 at 2:03 PM, the Administrator and the Maintenance Director stated the facility did not have documentation that demonstrated a risk assessment had been completed for building system's categories. The Administrator further stated, a risk assessment had not been conducted on the building system's categories in accordance with NFPA 99. Review of the facility's Emergency Evacuation and Mutual Aid Policy and Procedures manual with a revised date of 5/10/18 and the facility's Disaster Plan with a revised dated of 5/10/18 revealed they contained no documentation a risk assessment for the building system's categories was conducted in accordance with the 2012 edition of NFPA 99. Per the 2012 edition of NFPA 99, Health Care Facilities Code: building systems in health care facilities shall be designed to meet system Category 1 through Category 4 requirements as detailed in this code and the categories shall be determined by following and documenting a defined risk assessment procedure. 10NYCRR 415.29(a)(2),711.2(a)(1) 2012 NFPA 99: 4.1, 4.2, 4.3

Plan of Correction: ApprovedNovember 9, 2018

1a) A Risk Assessment for building system categories has been completed and properly documented b y the Administrator.
2. The Risk Assessment will be reviewed and updated annually.
3. The Administrator, Maintenance Director and Director of Nurses will be responsible for maintaining the facility risk assessment(NFPA 99) on an annual basis.
4. The Administrator will be responsible for maintaining the risk assessment and review at least annually with the facility QA committee.

K307 NFPA 101:GAS EQUIPMENT - CYLINDER AND CONTAINER STORAG

REGULATION: Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING." Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 16, 2018
Corrected date: December 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during a Life Safety Code survey completed on 10/16/18, oxygen cylinders and oxygen cylinder storage rooms were not properly maintained. Issues included, oxygen cylinders were improperly secured, were stored too closely to combustibles, and rooms in which oxygen cylinders were being stored were not lockable or did not have signage stating oxygen was being stored inside the rooms. This affected three (Unit 1-2, Unit 5 and Unit 6) of three resident units, and one of one Basement. The findings are: 1. Observation on the First floor, on Unit 1-2, on 10/9/18 at 9:46 AM, revealed an oxygen storage cabinet containing six E-size oxygen cylinders was stored in the clean utility room located near resident room [ROOM NUMBER]. Further observation at this time revealed the room's corridor door and the corridor walls around it did not have signage indicating oxygen was being stored in the room. Further observation revealed the corridor side of the room was not posted with signage stating oxygen was being stored inside the room. During the observation, the Maintenance Director stated he was not sure why the room's door did not have a sign stating oxygen was stored in the room. 2) Observation on the First Floor, on Unit 1-2, on 10/15/18 at 9:46 AM, revealed two E-size oxygen cylinders in two wheeled carts were stored in the clean utility room located near resident room [ROOM NUMBER]. The room's door did not have a locking mechanism. 3) Observation on the First Floor, on Unit 6, on 10/9/18 at 11:41 AM, revealed one E-size oxygen cylinder in a two-wheeled cart was stored less than five feet away from combustible materials including; an upholstered chair, a dry-erase board, and a partially full bin of paper to be shredded, in the oxygen storage room by Resident room [ROOM NUMBER]. Further observation at this time revealed the room's door did not have a locking mechanism. During the observation, the Maintenance Director stated he was not aware the room's door did not have a lock. 3) Observation on the First Floor, on Unit 5, on 10/9/18 at 11:07 AM, revealed one E-size oxygen cylinder in a nylon carrying case and one D-size oxygen cylinder in a nylon carrying case were stored upright and leaning against each other on top of the rack inside the oxygen storage cabinet in the clean linen/oxygen storage room located near Resident room [ROOM NUMBER]. During the observation, the Maintenance Director stated the oxygen cylinders should have been stored in the rack not on top of it. 4. Observation in the Basement on the B Wing, on 10/9/18 at 1:18 PM, revealed one D-size oxygen cylinder in a nylon carrying case was stored free standing and unsecured on the carpeted floor of laundry storage room B 12. Further observation at this time revealed the oxygen cylinder was stored within three inches of three eight-inch tall dead dried-out plants in plastic pots. Continued observation revealed the corridor side of the room was not posted with signage stating oxygen was being stored inside the room. During the observation, the Maintenance Director stated he had no idea why the oxygen cylinder was stored in the room. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 11.3.2, 11.3.2.1, 11.3.2.3(2), 11.3.4.1, 11.3.4.2, 11.3.2.6, 11.6.2.3(3)(11)

Plan of Correction: ApprovedNovember 9, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1a) An oxygen storage sign was placed next to the clean utility room on unit 1 and 2 by Resident room [ROOM NUMBER] to indicate oxygen is stored in that room.
b) A locking mechanism was placed on the door to the clean utility room located near Resident room [ROOM NUMBER].
c) The one E-size oxygen cylinder and the one D-size oxygen cylinder located in the clean linen/oxygen room on unit five were secured properly in the rack.
d) The D-size oxygen cylinder that was located in the laundry storage room b 12 was removed and stored in a proper approved location.
2. All licensed nurses and maintenance staff will be re-educated as to proper storage of oxygen by the RN Educator and a post test given. A 100% audit will be completed in all oxygen storage room to determine proper storage of oxygen. Any issues identified will be corrected and noted on the audit tool.
3. The Maintenance staff, weekly when delivering oxygen, will audit each oxygen storage area to identify if everything is stored correctly. The weekly audit tool will be updated for any corrections. Any trends identified by the Maintenance Director as far as improper storage of oxygen will be referred to the DON and RN Educator for re-education of the licensed staff for that unit. The Maintenance Director will review the weekly audit results with the Director of Nurses and Administrator for remedial action as needed. The Maintenance Director to monitor.
4. The Maintenance Director will present the findings of the weekly audits at the facility monthly QA meeting. The QA committee will make recommendations and or comments. The weekly audits will be on-going until four weeks of facility compliance are established. At that time, the oxygen storage audits will be completed monthly. The Administrator to supervise.

K307 NFPA 101:GENERAL REQUIREMENTS - OTHER

REGULATION: General Requirements - Other List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 16, 2018
Corrected date: December 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the Life Safety Code survey completed on 10/16/18, the facility did not maintain the building to minimize the possibility of a fire emergency requiring the evacuation of occupants and ceiling assemblies were not properly maintained. Issues included; excessive amounts of lint and dust in, on, and around the laundry's dryers and on the exterior of the building outside of the laundry room and ceiling tiles were missing from ceiling assemblies in rooms where smoke detectors and sprinkler heads had been installed. An intact ceiling assembly is designed to form a partition that traps heat and smoke and allows the smoke detectors and sprinkler heads to operate. The missing ceiling tiles would allow smoke and heat to continue into the void above the ceiling assembly instead of along the ceiling and could delay the operation of the smoke detectors and sprinkler heads. This affected one (Unit 5) of three resident units and one of one Basement. The findings are: 1) a) Observation in the laundry room, on 10/9/18 at 1:34 PM, revealed a 15 foot-long by three-foot wide section of the floor behind the five dryers was covered with a layer of lint and dust that ranged from one quarter-inch to two-inches in thickness. Further observation at this time revealed a 15-foot long by five-foot wide section of the wall behind the dryers was covered with a layer of lint and dust that ranged from one quarter-inch to one half-inch in thickness. Continued observation at this time revealed the tops and backs of the five dryers were covered with a layer of lint and dust that ranged from one quarter-inch to one half-inch in thickness. The ventilation ducts located behind the dryers were covered with a layer of lint and dust that ranged from one quarter-inch to one half-inch in thickness. During the observation the Maintenance Director stated, he had no documentation for the cleaning of the lint on or around the dryers and he was not sure when the dryers and areas above and behind them had been cleaned last. b) Observation on the exterior of the building at the area around the three exhaust vents from the laundry's clothes dryers, on 10/9/18 at 1:37 PM, revealed a 15-foot long by four-foot wide section of the ground was covered with a layer of lint and dust that ranged from one quarter-inch to three-inches in thickness. Further observation revealed a 12 foot-long by two-foot wide section of the building's exterior wall, including three windows installed through the wall, was covered with a layer of lint and dust that ranged from one quarter-inch to one half-inch in thickness. Continued observation at this time revealed the interior of all three vents were covered with a layer of lint and dust that ranged from one quarter-inch to one-inch in thickness. During these observations the Maintenance Director stated, he was not aware of the build-up of lint on the exterior of the building and inside the ventilation ducts. 2. a) Observations on the First Floor on Unit 5, on 10/9/18 at 11:26 AM and on 10/10/18 at 10:30 AM, revealed a smoke detector and sprinkler head were installed from the ceiling of the storage closet located in the therapy room. Further observation at this time revealed two, four-foot long by two-foot wide ceiling tiles were missing from the ceiling assembly in the closet. During this observation, the Maintenance Director stated he was not aware the ceiling tiles had been removed. b) Observation in the Basement, on 10/9/18 at 12:36 PM, revealed two smoke detectors and sprinkler heads were installed from the ceiling of the activities storage room. Further observation at this time revealed one, four-foot long by two-foot wide and one, two-foot long by two-foot wide ceiling tiles were missing from the ceiling assembly in the activities storage room. During this observation, the Maintenance Director stated he was not aware the ceiling tiles had been removed and he was not aware of any recent work being done above the ceiling tiles in the room. c) Observation on the First Floor Unit 5, on 10/11/12/18 at 12:34 PM, revealed a smoke detector and sprinkler head were installed from the ceiling in Resident room [ROOM NUMBER]. Further observation at this time revealed a two-foot long by one-foot wide ceiling tile was missing from the room's ceiling assembly. During this observation, the Maintenance Director stated he did not know why the ceiling tile was missing from the room's ceiling. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.1.1.3.1, 4.6.12.2

Plan of Correction: ApprovedNovember 20, 2018

1a) The floor area behind the five dryers was cleaned and dust removed. The wall behind the dryers was cleaned and dust removed. The ventilation ducts behind the dryers were cleaned and rear cleaned.
b) The area on the exterior of the building behind the three exhaust vents was cleaned of lint to include exterior wall, windows and ducts This included the ground area, exterior wall and the three vents.
c) Smoke detector and sprinkler head located in the Therapy Room on first floor have been installed properly and the ceiling tiles have been replaced.
d) The two smoke detectors and sprinkler heads located in the activities lounge have been installed properly and the ceiling tiles have been replaced. The area behind, above and outside were cleaned of lint.
e) The smoke detector and sprinkler head in Resident Room # 522 have been installed properly. The ceiling tile was replaced.
(2)A 100% audit to identify missing ceiling tiles was completed. Any area identified as having missing ceiling tiles was replaced by the Maintenance Department.
(3) The Maintenance Department will be educated by the Administrator to replace any and all ceiling tiles removed for repairs or outside vendors as soon as repair work is completed and the necessity of maintaining a lint free environment in the laundry area. The lint cleaning by the maintenance department will occur by the last day of each month and verified by the Administrator all areas referenced remain free of lint. A monthly audit will be completed to identify any missing ceiling tiles in Resident rooms and common areas. Any area identified will be corrected within 7 days and noted on monthly audit. The Maintenance Department will be responsible.
(4) The monthly ceiling tile audit as well as laundry room inspection for lint both inside and outside the laundry room area will be reviewed at the monthly QA meeting by the Maintenance Director. The audit will include # of missing ceiling tiles vs. replaced ceiling tiles and the results of the verified audit for lint cleaning. These audits will occur monthly x 3 months then quarterly. Administrator to supervise.

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: October 16, 2018
Corrected date: December 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during a Life Safety Code survey completed on 10/16/18, hazardous areas were not properly maintained. Issues included, hazardous area doors that did not self-close and latch into their door frames and were not designed to resist the passage of smoke due to unsealed penetrations. This affected two (Unit 1-2 and Unit 6) of three resident units, one of one Second Floor (administration) and one of one Basement. The findings are: 1. a) Observation on the Second Floor, on 10/9/18 at 9:35 AM, revealed the corridor door to the Health Information Management office would not self-close and latch into its door frame. Continued observation revealed the room was greater than 50 square feet in size and at least 20 cardboard boxes, full of paperwork containing resident information, were stored in the room. Continued observation at this time revealed a sign posted on the door read as follows, Please lock and pull door closed when you leave. Thank You. b) Observation on the First Floor, Unit 1-2, on 10/9/18 at 9:48 AM, revealed the corridor door to the soiled utility room located near Resident room [ROOM NUMBER] would not self-close and latch into its door frame. Further observation revealed the door's latch was missing. Continued observation at this time revealed three full 32-gallon soiled linen receptacles, one full 115-gallon soiled linen receptacle, and two full 32-gallon trash receptacles were stored in the room. During the observation, the Maintenance Director stated he was not aware the door's latch was missing. The Maintenance Director further stated the facility had no documentation for the inspection and testing of the building's hazardous area doors. c) Observation in the Basement, on the Center Core, on 10/9/18 at 12:22 PM, revealed one of the double corridor doors (the right door as one looked at the room from the Basement corridor) to the LaVerna storage room would not self-close and latch into its frame. Further observation revealed a one half-inch penetration through the door. Continued observation at this time revealed the room was greater than 50 square feet in size and used to store the following items: an open partially full one-gallon can of flammable paint thinner, one partially full one-gallon can of flammable adhesive remover, eight bed frames, two mattresses, six wheelchairs, three roller walkers, four overbed tables. two toilets, four tables, four wooden pallets, one eight-foot long by four-foot wide wooden crate, 24 five-gallon buckets of paint, four five-gallon buckets of vinyl adhesive,12 cases of tiles, 12 boxes of door edge guards, one wet/dry vacuum. During the observation, the Maintenance Director stated the room was being us to stored construction supplies. 2. a)Observation on the First Floor, Unit 6, on 10/9/18 at 11:35 AM, revealed the corridor door to the soiled utility room located near Resident room [ROOM NUMBER] had a one quarter-inch circular penetration through the door, above the door's handle. Further observation at this time revealed the room was greater 50 square feet in size and contained three full 32-gallon soiled linen receptacles, one full 115-gallon soiled linen receptacle, and one full 32-gallon trash receptacle. During the observation, the Maintenance Director stated he was not aware of the penetration through the door. b) Observation in the Basement, on the C Wing, on 10/9/18 at 1:47 PM, revealed the corridor door to storage room C13 (dietary storage room) would not self-close and latch into its frame. Further observations revealed there was a two-inch circular penetration through the door and the door's handle and latching mechanism were missing. Continued observation at this time revealed the room was greater than 50 square feet in size and contained storage racks of full of cardboard boxes containing plastic cups, plastic cup lids, foam cups and paper plates. During the observation, the Maintenance Director stated he was not aware the door's handle was missing. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.2.1

Plan of Correction: ApprovedNovember 20, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1a) The Health Information Management office door on the second floor with a self closing device was fixed to close properly.
b) The corridor door to the soiled utility room located near Resident room [ROOM NUMBER] which has a self closing device on it was fixed to close and latch properly.
c) The door in the basement to the LaVerna room which has a self closing door was fixed to close and latch properly.
d) The one quarter inch circular penetration to the corridor door to the utility room located near Resident room [ROOM NUMBER] was sealed with a fire restricted approved rated material.
f) The corridor door to storage room [ROOM NUMBER] (dietary storage room) had it's handle replaced and the two inch circular penetration sealed properly.
(2) a 100% audit was completed of all hazardous to include: Laundry, Maintenance shop, soiled utility rooms, trash collection rooms and medical records room to ensure all doors close and latch. Any area identified noted during the audit and corrected. All Department Directors were re-educated by the Administrator to the function of hazardous area doors and well as conducting monthly audits to ensure areas are free of obstruction as it relates to their area within the building.
(3) Maintenance staff will conduct a monthly audit of all hazardous areas to ensure doors close and latch properly. Any areas identified will be noted and corrected. Maintenance Director to monitor.
(4) Audits will be presented for review at the monthly QA meeting. Administrator to supervise.


MAINTENANCE, INSPECTION & TESTING - DOORS

REGULATION: Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 16, 2018
Corrected date: December 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during a Life Safety Code survey completed on 10/16/18, fire rated doors were not properly maintained. Issues included, the facility did not have documentation that demonstrated the building's fire rated doors had been inspected and tested at least annually. This affected two (Unit 1-2, and unit 6) of three resident units, one of one Second Floor (administration), and one of one Basement. The findings include but are not limited to: 1. During an interview on 10/15/18 at 8:28 AM, the Maintenance Director stated the facility had no documentation for the inspection and testing of the building's fire rated doors. a) Observations on 10/15/18 at 8:35 AM revealed the Unit 1-2 cross-corridor smoke barrier doors located near resident rooms [ROOM NUMBERS] had a fire ratings labels attached to them stating the doors had a 20-minute fire resistance rating. b) Observations on 10/15/18 at 8:41 AM revealed the Unit 5 cross-corridor smoke barrier doors located near resident rooms #520 and 521 had a fire ratings labels attached to them stating the doors had a 20-minute fire resistance rating. c) Observations on 10/15/18 at 8:41 AM revealed the Second Floor (administration), corridor door to the conference room had a label attached to it indicating the door had a 90-minute fire resistance rating. d) Observations on 10/15/18 at 10:16 AM revealed the Basement (Center core), corridor door to the LaVerna storage room had a label attached to it stating the door had a one-hour fire resistance rating. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.7.6, 8.3.3.1 2010 NFPA 80: 5.2.1

Plan of Correction: ApprovedNovember 9, 2018

1a) All fire doors were inspected in accordance with NFPA 80.
2. The Maintenance Department will be educated on NFPA 80 and the annual requirements for inspection of non-rated doors, including corridor doors and smoke barrier doors, documentation of the inspection and record keeping. An outside vendor will be contacted to educate and complete the first inspection.
3. The annual door inspection will be added to the master calendar by the Maintenance Director and a copy provided to the Administrator. The first inspection and education will be scheduled. The doors inspected will be listed on an audit tool and any corrections needed will be so noted on the audit tool. The Maintenance Director will complete a random sample to verify corrections were made. The Maintenance Director to monitor this paln.
4. The Maintenance Director will review at the facility QA meeting the results of the annual door inspection. The QA committee will make comments and/or recommendations. The inspection will be entered into the QA minutes. A copy of the master schedule will be distributed and entered into the minutes. The Administrator to supervise this plan.

K307 NFPA 101:MEANS OF EGRESS - GENERAL

REGULATION: Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 16, 2018
Corrected date: December 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during a Life Safety Code survey completed on 10/16/18, means of egress were not continuously maintained free of all obstructions or impediments to full instant use, in the event of fire or other emergency. Issues included, an exit door was obstructed from being opened, the path of egress to exit doors was obstructed and items were being stored in exit egress corridors. This affected two (Unit 1-2 and Unit 5) of three resident units and one of one Basement. The findings are: 1. Observation on 10/9/18 at 10:29 AM revealed exit door #15,would not open. Continued observation at this time revealed the Maintenance Director attempted to open the door three times but the door would not open. Exit door #15 was located on the Basement level, and was the stairway exit door that served Unit 1-2 on the First Floor near Resident room [ROOM NUMBER] as well as the basement level. Further observation revealed exit door #15 lead directly from the stairway to the exterior of the building. Observation on the exterior of the building, on 10/9/18 at 10:30 AM, revealed exit door #15 was hung up on a wooden ramp that was part of the exterior path of egress from the door to the public way (the parking lot). During the observation, the Maintenance Director stated the door was hung up on the ramp and he was not aware the door could not be opened. The Maintenance Director further stated the facility had no documentation for the inspecting and testing of the building's exit doors. 2. a) Observation on the Center Core of the Basement, on 10/9/18 at 12:22 PM, revealed a bed frame, an over bed table, and boxes of tiles, were stored in front of and obstructing the path of egress to the exit door of the LaVerna storage room that opened into the Center Stairway. Further observation at this time revealed the door had an exit sign installed above it. During the observation, the Maintenance Director stated the bed frame should not have been stored in front of the exit door. b) Observation on the First Floor, Unit 5, on 10/12/18 at 7:31 AM, and again on 10/16/18 at 8:13 AM revealed a rocking chair and a high back upholstered chair were stored in front of and obstructing the path of egress to exit door #10. Further observation at this time revealed the door had an exit sign installed above it. Continued observation at this time revealed exit door #10 lead directly from the dining room to the exterior of the building. 3. Observation on the A-Wing, in the Basement, on 10/9/18 at 12:46 PM revealed the following items were stored in the corridor: - two gehri style chairs - two roller walkers - one four-foot long by four-foot wide wooden pallet containing 54 wooden table tops - one four-foot long by four-foot wide wooden pallet containing 32 wooden cabinet doors During the observation, the Maintenance Director stated the items had been stored in the corridor for at least two weeks. Observation on the A-Wing, in the Basement, on 10/15/18 at 10:18 AM revealed the following items remained stored in the corridor: - one four-foot long by four-foot wide wooden pallet containing 54 wooden table tops - one four-foot long by four-foot wide wooden pallet containing 32 wooden cabinet doors 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2102 NFPA 101: 19.2.1, 7.1, 7.1.1, 7.1.10.1

Plan of Correction: ApprovedNovember 20, 2018

1a) Exit door #15 located in the basement that leads to Units 1 & 2 was fixed to open properly.
*All other exit doors were audited and they open fine.
b) The bed frame, over bed table and boxes of tiles were move to proper storage away from the entrance to the LaVerna storage room door.
c) The rocking chair and high back upholstered chair were moved to proper storage and away from blocking exit door #10.
d) The two Gehri chairs, two roller walkers, pallet containing 54 wooden table tops and pallet containing 32 wooden cabinet doors were removed from the A-wing basement corridor.
(2) a 100% audit of all exit doors for proper functioning and obstruction was completed. Any area identified was repaired and/or adjusted.
(3) The Maintenance staff will be re-educated on the proper operation of doors, audit schedules, and maintaining egresses free of items by the Administrator. The Maintenance Department will audit all exit doors monthly for proper fit and obstructions. All corrections will be noted on audit tool and reviewed by Administration. Maintenance Director will be responsible.
(4) The monthly exit door audit and findings will be reviewed at the monthly QA meeting. The review will go over any needed corrections. The Administrator to supervise.

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: October 16, 2018
Corrected date: December 14, 2018

Citation Details

Based on observation and interview during a Life Safety Code survey completed on 10/16/18, portable fire extinguishers were not properly maintained. Issues included, portable fire extinguishers were obstructed, were not securely hung, were installed too high above a floor's surface, and a portable fire extinguisher with a gauge showing the extinguisher needed to be recharged was still in service. This affected one (First Floor) of one resident use floor, one (Unit 6) of three resident units and one of one Basement. The findings include but are not limited to: 1. a) Observation in the Basement, on the A Wing, on 10/9/18 at 8:53 AM revealed two high back upholstered chairs were obstructing the portable fire extinguisher located near the activities room. During an interview at the time of this observation, the Maintenance Director stated the staff knew they were not to block the fire extinguishers. b) Observation in the Basement, on the C Wing, on 10/9/18, at 1:56 PM revealed an overbed table with a television on it and a three-foot tall cart full of hand tools, battery operated power tools, equipment parts, and cords were obstructing the portable fire extinguisher located in the Maintenance Shop. 2. Observation on the First Floor, on Unit 6, on 10/9/18 at 11:47 AM, revealed the portable fire extinguisher located in the dining room was hung from a bracket by its pin, instead of from the eye hook located on the back of the extinguisher. During the observation, the Maintenance Director stated the extinguisher should not have been hung from its pin. 3. a) Observation in the Basement, on the B Wing, on 10/9/18 at 1:30 PM, revealed the portable fire extinguisher located near the clothes dryers was installed greater than five feet above the floor's surface. b) Observation in the Basement, on the C Wing on 10/9/18 at 1:55 PM, revealed the portable fire extinguisher located near the Meditation room #C5 was installed greater than five feet above the floor's surface. During an interview on 10/16/18 at 9:06 AM, the Maintenance Director stated he was not aware the extinguishers were installed too high above the floor. 4. Observation on the First Floor, in the Kitchen, on 10/9/18 at 3:14 PM, revealed the gauge on the K-type fire extinguisher indicated the extinguisher needed to be recharged. During the observation, the Maintenance Director stated he was not aware of any issues with the fire extinguishers. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 9.3.5.12, 9.7.4.1 2010 NFPA 10: 6.1.3.4(1), 6.1.3.8.1, 7.2.2(2)(3)

Plan of Correction: ApprovedNovember 20, 2018

1a) The two high back chairs that were obstructing the portable fire extinguisher by the Activities room were moved .
1b) The over bed table with a television on it and a three foot tall cart full of hand tools, battery operated power tools, equipment parts, and cords that were obstructing the portable fire extinguisher were removed .
2a) The portable fire extinguisher located in the dining room on unit six was secured properly using the eye hook
3a) The portable fire extinguisher located in the b-wing of the basement near the clothes dryers was lowered below the 5 foot height requirement.
3b) The portable fire extinguisher located in the basement on the c-wing near the meditation room was lowered below the 5 foot height requirement.
4a) The gauge on the K-type fire extinguisher located in the first floor kitchen was recharged.
2. A 100% inspection of all fire extinguishers was completed to include charged and proper storage. Any extinguisher identified as needing attention will be noted and corrected during the inspection by maintenance staff. The Maintenance staff were re-educated by the Administrator as it relates to securely hanging extinguishers and the proper height.
3. The Maintenance Director will modify the existing policy to be included during the monthly inspection for storage and noting any units needing charging. The Maintenance Director will monitor the completion of this task by his staff. A copy of this inspection will be reviewed with the Administrator.
4. The maintenance director will review at the monthly facility QA meeting the results of the monthly audits that include this inspection. The Maintenance Director as supervised by the Administrator will report compliance percentage to areas requiring correction. The QA committee will make comment and or additional recommendations. The monthly inspection will be on-going.

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

REGULATION: Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 16, 2018
Corrected date: December 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during a Life Safety Code survey completed on 10/16/18, sprinkler piping that was not properly installed. Issues included sprinkler piping was hung from electrical conduits and insulated piping, instead of from the building's structure. This affected two (Units 1-2 and Unit 6) of three resident units. The findings are: 1. a) Observation above the First Floor ceiling tiles on Unit 1-2, on 10/10/18 at 10:00 AM, revealed a sprinkler pipe was hung from an electrical conduit located in Resident room [ROOM NUMBER]. During this observation, the Maintenance Director stated he was not aware the sprinkler pipe was hung from the electrical conduit. b) Observation above the First Floor ceiling tiles On Unit 6, on 10/10/18, at 10:40 AM, revealed a sprinkler pipe was hung from an insulated pipe located in the beauty shop. During this observation the Maintenance Director stated, he was not aware the sprinkler pipe was hung from the pipe. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 9.7.1.1(1) 2010 NFPA 13: 9.2.1.3.1

Plan of Correction: ApprovedNovember 9, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1a) The sprinkler pipe hung from an electrical conduit located in Resident room [ROOM NUMBER] was moved to a proper location.
b) The sprinkler pipe hung from an insulated pipe located in the beauty shop was moved and secured properly.
2. The sprinkler company that installed the sprinkler system will be requested to return to the facility to inspect the location of all sprinkler pipes to be properly installed. The vendor will be requested to note any areas noted as needing relocation to note it on the work order and document findings of location and repair. The Maintenance director and or designee to validate corrections.
3. Any work completed on the sprinkler system as it relates to maintenance and testing will be requested to document on all work orders that pipes are properly positioned and such dated. The Maintenance Director and or designee to validate any re-positioning. The Maintenance Director to monitor. All findings or lack there of will be reviewed with the Administrator.
4. Any life safety testing will be reviewed at the monthly facility QA meeting by the maintenance director to identify areas needing correction and date of that correction. The QA committee will make comment and or additional recommendations. The Administrator to monitor.

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

REGULATION: Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 16, 2018
Corrected date: December 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during a Life Safety Code survey completed on 10/16/18, the building's automatic sprinkler system was not properly maintained. Issues included: items were stored less than 18 inches away from sprinkler heads and obstructing sprinkler heads, an internal inspection of the building's sprinkler system piping had not been conducted in the past five years and no hydrostatic testing of the building's fire department connection had been conducted in the past five years. This affected three (Unit 1-2, Unit 5, and Unit 6) of three resident units, one of one Second Floor (administration), one of one garage and one of one Basement. The findings include but are not limited to: 1. a) Observation on the Second Floor, on 10/9/18 at 9:07 AM, revealed three, three-ring binders and 20 folders were stored on a shelf less than 18 inches away from and directly below a sprinkler head in a closet in the Director of Social Work's office. b) Observation on the Second Floor, on 10/9/18 at 9:16 AM, revealed a cardboard box was stored on a shelf less than 18 inches away from and directly below a sprinkler head in storage room [ROOM NUMBER]. During an interview, at the time of the observation, the Maintenance Director stated the facility did not have any documentation for audits to ensure items were not stored too closely to sprinkler heads. c) Observation on the Second Floor, on 10/9/18 at 9:33 AM, revealed stacks of paper and cardboard folders were stored on a shelf less than 18 inches away from and directly below a sprinkler head in a closet in the Finance Coordinator's office. d) Observation in the garage, on 10/9/18 at 10:32 AM, revealed a five-foot long by three-foot wide piece of vinyl flooring and four, five-foot long by one-foot wide metal racks were stored on the rafters obstructing the spray pattern of an upright sprinkler head. During this observation, the Maintenance Director stated he was not aware the sprinkler head was obstructed. 2. During an interview on 10/16/18 the Maintenance Director stated, the facility had no documentation that an internal inspection of the building's sprinkler piping had been conducted in the last five years or that hydrostatic testing of the building's fire department connection had been conducted in the past five years. Review of a Dry Fire Sprinkler Inspection and Wet Fire Sprinkler inspection reports dated 9/13/18 revealed no internal inspection of the building's sprinkler system piping had been conducted in the past five years and no hydrostatic testing of the building's fire department connection had been conducted in the past five years. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 9.7.5, 9.7.8 2011 NFPA 25: 14.2.1, 6.3.2.1

Plan of Correction: ApprovedNovember 20, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1a) The three, three ring binders and 20 folders stored less than 18 inches below a sprinkler head in the Director of Social Work's office were removed and stored properly.
b) A card board box stored less than 18 inches away from and below a sprinkler head stored in storage room [ROOM NUMBER] was removed and stored properly.
c) The stacks of paper and cardboard folders stored on a shelf less than 18 inches away from and directly below a sprinkler head were removed and stored properly.
d) The five foot long by three foot wide piece of vinyl flooring and four, five foot long by one foot wide metal racks stored in the rafters of the garage were removed and stored properly.
e) A internal inspection of the building's sprinkler system piping and the hydro-static testing of the building's fire department connections will be scheduled now and again in five years.
2. A 100% audit of all closet, garage and storage areas will be completed to maintain no storage of items within 18 inches of the ceiling. All Department Directors will be re-educated as it relates to storage of items not within 18 inches of a sprinkler head by the Administrator.
3. The Maintenance Director will develop a master calendar to include all mandatory testing of life safety equipment to include, but not limited to the hydrostatic testing to the fire department and the inspection of the internal sprinkler piping. The Master calendar will be reviewed by the maintenance Director with the administrator on a monthly basis to confirm appointments have been made and when vital inspections are occurring. After the completion of the major testing, the Maintenance Director will review those findings with the Administrator. The Maintenance Director will be responsible to schedule all mandatory testing. On a quarterly basis, the Maintenance staff mark each storage area to indicate 18 inches so as not to store in close proximity to a sprinkler head. All Department Directors to be educated by the Maintenance Director the color of the mark and the importance of monitoring the storage of items too near a sprinkler head.
4. After each major life safety testing, the Maintenance Director will review at the monthly QA meeting the findings of the testing, items needing attention and completion of identified items. The QA committee will make comment and or additional recommendations. The Administrator to supervisor this plan.

K307 NFPA 101:STAIRWAYS AND SMOKEPROOF ENCLOSURES

REGULATION: Stairways and Smokeproof Enclosures Stairways and Smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 16, 2018
Corrected date: December 14, 2018

Citation Details

Based on observation and interview during a Life Safety Code survey completed on 10/16/18, stairways were not properly maintained. Issues included, storage in stairways, and stairway exit doors that did not self-close and latch into their door frames. This affected one (Unit 5) of three resident units, one (First Floor) of one resident use floor, one of on Second Floor (administration) and one of one Basement. The findings are: 1. a) Observation on the First Floor in the Center Stairway, on 10/9/18 at 8:48 AM, revealed one partially full 115-gallon soiled linen receptacle was stored on the stairway's First Floor landing and one partially full 115-gallon trash receptacle was stored on the stairway's Basement landing. Further observation at this time revealed the Center Stairway served the Basement, First Floor, and Second Floor. During an interview on 10/9/18 at 8:51 AM the Maintenance Director stated he was not sure why the soiled linen receptacles were stored in the stairway. b) Observation in the Basement, on 10/9/18 at 10:33 AM, revealed a four-foot tall by two-foot wide pedestal floor fan was stored in the stairway located near the rear of the laundry room. During the observation, the Maintenance Director stated he was not aware the fan was being stored in the stairway and the staff knew not to store things in the stairways. c) Observation in the Basement Center Stairway on 10/9/18 at 12:15 PM revealed one partially full 115-gallon trash receptacle was stored on the stairway's Basement landing. During the observation, the Maintenance Director stated he was not sure why the receptacle was stored in the stairway and it should not have been stored in the stairway. 2) a) Observation on the First Floor Unit 5, on 10/9/18 at 11:19 AM, revealed exit door #11, located near Resident Rooms #535 and 536, would not self-close and latch into its door frame. During the observation, the Maintenance Director stated the facility had no documentation for the inspection and testing of the building's stairway exit doors. b) Observation on the First Floor, in the dining room located in front of the Kitchen, on 10/9/18 at 3:24 PM, revealed exit door #21, located near the entrance to the Kitchen, would not self-close and latch into its door frame. Further observation revealed the stairway served the First Floor and the Basement. During the observation, the Maintenance Director stated he was not aware the door would not self-close and latch into its door frame. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.2.2.3, 7.2.2, 7.2.2.1.1, 7.1, 7.1.3.2.3

Plan of Correction: ApprovedNovember 9, 2018

1a) The 115 gallon soiled linen receptacle on the landing of the first floor and the 115 gallon trash receptacle stored on the basement's stairwell landing were removed and stored properly.
b) The four foot by two foot pedestal fan was removed from the stairwell located near the rear of the Laundry room.
c) The 115 gallon trash receptacle that was stored on the stairway's basement landing was removed and stored properly.
d) Exit door #11 located near rooms #535 and #536 was fixed to self close and latch properly.
e) Door #21 located near the entrance to the kitchen was fixed to self close and latch properly.
(2) A 100% audit of all corridor doors was completed to identify any doors that wouldn't latch. The Environmental/Laundry Director, Food Service Director and Maintenance Director were re-educated about proper storage of garbage receptacles, fans etc. They will re-educate their staffs.
(3) A monthly audit will be completed by Maintenance staff to identify any corridor doors that fail to latch. Repairs to be noted on audit. Any storage identified in prohibited areas will be reported to the Administrator for follow up. The Maintenance Director to monitor.
(4) The audits will be ongoing. Results of audits will be reviewed at the monthly QA meeting. Administrator to supervise.

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 16, 2018
Corrected date: December 14, 2018

Citation Details

Based on observation and interview during a Life Safety Code survey completed 10/16/18, smoke barriers were not properly maintained. Issues included, smoke barrier walls were not complete from floor to ceiling/ roof deck, were not designed to have at least a 30-minute fire resistance rating, and were not designed to resist the passage of smoke, due to unsealed penetrations. This affected three (Unit 1-2, Unit 5, and Unit 6) of three resident units. The findings are: 1. a) Observations above the First Floor corridor ceiling tiles, on Unit 1-2, on 10/10/18 at 9:26 AM, revealed: a one-half-inch long by one-half-inch wide, a one-inch long by one-half-inch wide, and a four-inch long by two-inch wide penetration, through the smoke barrier wall above the smoke barrier doors near Resident Room #103. Further observation revealed a two-foot long by one-inch wide penetration, above a ventilation duct, was filled with pink colored fiber glass insulation. During the observation, the Maintenance Director stated he was not aware of the penetrations through the smoke barrier wall. The Maintenance Director further stated the facility had no documentation for the inspection of smoke barrier walls. b) Observation above the First Floor ceiling tiles, on Unit 1-2, on 10/10/18 at 10:00 AM, revealed a two-inch long by two-inch wide penetration above an electrical wire that was installed through the smoke barrier wall in Resident Room #202. Further observation revealed a one-inch long by one-inch wide penetration below the plumbing pipes that were installed through the room's smoke barrier wall. c) Observation above the First Floor ceiling tiles, on Until 5, on 10/10/18 at 10:50 AM, revealed a ten-inch long by eight-inch wide penetration above a quarter-inch gray electrical wire that was installed through the smoke barrier wall in Resident Room #520. d) Observation above the First Floor corridor ceiling tiles, on Unit 5, on 10/10/18 at 10:52 AM, revealed a ten-inch long by three-inch wide penetration through the smoke barrier wall above the smoke barrier doors near Resident Room #521. Further observations revealed the penetration was behind a pipe that was installed through the ceiling/ roof of the building and appeared to be a roof drain. Continued observation at this time revealed a six-inch long by two-inch wide penetration through the smoke barrier wall was filled with mineral wool that was not sealed with a fire rated material. During the observation, the Maintenance Director stated the pipe that was installed through the ceiling and roof was a roof drain. e) Observation above the First Floor corridor ceiling tiles, on Unit 6, on 10/10/18 at 12:05 PM, revealed a three-inch long by one-half-inch wide penetration above a sprinkler pipe that was installed through the smoke barrier wall above the smoke barrier doors near Resident Rooms #624 and 625. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101:19.3.7, 19.3.7.3, 8.5, 8.5.1, 8.5.2, 8.5.2.1, 8.5.2.2

Plan of Correction: ApprovedNovember 9, 2018

1a) The penetrations above the ceiling tiles on unit 1-2 near Resident room #103 were properly sealed with fire restricted approved fire rated caulk.
b) The penetrations above the first floor ceiling tiles on units 1-2 by Resident room #202 above the electrical wire was sealed with fire restricted approved fire rated caulk.
c) The ten inch long by eight inch wide penetration above a grey electrical wire by Resident room #520 was fixed ans sealed with fire restricted approved fire rated caulk.
d) The ten inch long by three inch wide penetration through the smoke barrier wall above the smoke barrier doors near Resident room #521 was fixed and sealed with fire restricted approved fire rated caulk. The six inch long by two inch wide penetration through the smoke barrier wall that had mineral wool was fixed and sealed with fire restricted approved fire rated caulk.
e)The three inch long by one half inch wide penetration above a sprinkler pipe installed through the smoke barrier wall near Resident rooms #624 and #625 was fixed and sealed with fire restricted approved fire rated caulk.
(2) A 100% audit of all smoke barrier walls above the ceiling tiles was completed. Any areas identified s needed repair were fixed using approved fire caulk material.
(3) The Maintenance Department will audit monthly smoke barrier walls for any penetrations. Any repairs will be noted on the audit tool and reviewed by the Administrator. Maintenance Director will monitor.
(4) The monthly audits will be reviewed at the monthly QA meeting. Administrator to supervise.


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: October 16, 2018
Corrected date: December 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during a Life Safety Code survey completed 10/16/18, smoke barrier doors were not properly maintained. Issues included, smoke barrier doors were not designed to resist the passage of smoke. This affected two (Unit 1-2 and Unit 6) of three resident units. The finding is: Observation on the First Floor, Unit 6, on 10/9/18 at 11:33 AM, revealed when the smoke barrier doors located near Resident room [ROOM NUMBER] were released from their magnetic hold open devices and allowed to close, there was a seven-foot long by one-inch wide gap between the doors. Further observation revealed the door located closest to Resident room [ROOM NUMBER] was hung up on the door's frame. Continued observation at this time revealed the gap between the smoke barrier doors affected resident rooms on Unit 1-2 due to the configuration of the building's smoke barrier walls. During the observation, the Maintenance Director stated he was not aware of any issues with the building's smoke barrier doors. The Maintenance Director further stated the facility had no documentation for the inspection and testing of the building's smoke barrier doors. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.7.8, 8.5.4.1

Plan of Correction: ApprovedNovember 20, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1a) The smoke barrier door located near resident room [ROOM NUMBER] had the seven foot long by one inch wide gap fixed and the frame was adjusted to close and seal properly. The smoke barrier doors between Units 1 and 2 were assessed by an outside vendor.
2. A 100% audit of the facility was completed on all smoke barrier doors and magnetic release operation. Any issues noted were corrected and noted on the audit tool. The maintenance staff were re-educated by Administrator as properly maintaining smoke barrier doors.
3. A monthly smoke barrier doors that release will be inspected on a monthly basis for proper operation by the Maintenance department. The Maintenance Director will monitor. Any issues noted during the audit as it relates to the proper functioning of the barrier doors will be corrected. The Maintenance Director will randomly validate that corrections have been made and noted on the monthly audit. The audit will be reviewed with the Administrator.
4. The Maintenance Director will review the findings of this monthly audit at the monthly facility QA for additional comments and or recommendations. The Maintenance Director will monitor for compliance. This audit will be on-going. The Administrator to supervise.

K307 NFPA 101:VERTICAL OPENINGS - ENCLOSURE

REGULATION: Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 16, 2018
Corrected date: December 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during a Life Safety Code survey completed on 10/16/18, stairways were not properly maintained. Issues included stairways were not enclosed with construction having a fire resistance rating of at least one-hour due to unsealed penetrations through the fire rated walls . This affected three (Unit 1-2, Unit 5, and Unit 6) of three resident units and one of one Basement. The findings are: 1. a) Observation in the Basement, on the B Wing, on 10/9/18 at 10:32 AM revealed a one-half inch long by one-half inch wide penetration above an electrical wire that was installed through the stairway wall that separated the stairway, located near the rear of the Laundry room, from the garage. During the observation, the Maintenance Director stated he was not aware of the penetration through the stairway wall. b) Observation above the First Floor corridor ceiling tiles on Unit 1-2, on 10/10/18 at 9:35 AM, revealed a one-inch penetration around a four-inch sprinkler pipe that was installed through the stairway wall that separated the stairway from the Unit 1-2 corridor. Further observation at this time revealed the penetration was located above stairway exit door #3. During the observation, the Maintenance Director stated he was not aware of the penetration. c) Observation above the First Floor corridor ceiling tiles on Unit 5, on 10/10/18 at 11:00 AM, revealed a one half-inch circular penetration above a white electrical wire that was installed through stairway wall that separated the stairway from the Unit 5 corridor. Further observations revealed the penetration was located above stairway exit door #11, located near Resident Rooms #535 and 536. During the observation, the Maintenance Director stated he was not aware of the penetration. d) Observation above the First Floor corridor ceiling tiles on Unit 6, on 10/10/18 at 12:13 PM, revealed a two-inch circular penetration above a sprinkler pipe that was installed through the stairway wall that separated the stairway from the Unit 6 corridor. Further observation at this time revealed the penetration was above stairway exit door #14, near Resident room [ROOM NUMBER]. During the observation, the Maintenance Director stated he was not aware of this penetration. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.1.1

Plan of Correction: ApprovedNovember 9, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1a) The one half inch by one half inch penetration above an electrical wire that was installed through the stairwell wall that separated the stairway, located near the rear of the Laundry Room, from the garage was sealed using fire restricted approved fire caulk.
b) The one inch penetration around a four inch sprinkler pipe that was installed through the stairwell wall that separated the stairway from unit 1 and 2 was sealed using fire restricted approved fire caulk.
c) The one half inch circular penetration above stairway exit door #11, located near Resident rooms #535 and #536 was sealed using fire restricted approved fire caulk.
d) The two inch circular penetration by unit six on the first floor that was installed through the stairway wall that separated the stairway from unit six corridor located above stairway exit door #14, near Resident room [ROOM NUMBER]^34 was sealed using fire restricted approved fire caulk.
(2) A 100% audit was completed on all stairways for penetrations. Any areas identified were sealed with a fire rated chalk and noted on audit.
(3) The Maintenance Department will be educated that they will be in attendance when an outside vendor is in the building for repairs. Any penetrations as a result of repair work will be sealed by Maintenance Department after vendor completes work. Maintenance Director monitors.
(4) Maintenance Director will observe all vendor areas on a monthly audit to verify are sealed. Audit will be presented at monthly QA meeting. Administrator to supervise.