Fiddlers Green Manor Rehabilitation and Nursing Center
May 9, 2017 Certification/complaint Survey

Standard Health Citations

FF10 483.90(d)(2)(e):ESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION

REGULATION: (d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition. (e) Resident Rooms Resident rooms must be designed and equipped for adequate nursing care, comfort, and privacy of residents.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 9, 2017
Corrected date: July 1, 2017

Citation Details

Based on observation and interview during the Standard survey completed 5/9/17, the facility did not assure that all essential mechanical, electrical and patient care equipment was in safe operating condition. One (Third Floor) of three resident use floors observed for the maintenance of equipment had issues involving plumbing that lacked a vacuum breaker (a device that prevents contaminated or waste water from being siphoned backward into the public drinking water system) to ensure that waste water would not be siphoned backward into the building's potable water supply. The findings are: 1. Observation of the Third Floor on 5/3/17 at approximately 11:06 AM revealed the hose for the hopper sink, located in the soiled utility room, was submerged approximately two inches below the surface of the water located inside of the hopper. Further observation at this time revealed the rinse water hose/wand for the soiled hopper, was directly plumbed into the clean water supply pipe, located below the hand washing sink. Continued observation at this time revealed the hose/wand and water pipe did not have vacuum breakers installed on them. An interview with the Maintenance Supervisor, at the time of the observation, revealed the hopper's hose and the water line it was connected to did not have vacuum breakers installed on them to prevent wastewater from backflowing into the potable water supply for the facility. Further interview with the Maintenance Supervisor, at this same time, revealed he was not aware that the hose had been connected to the water supply line without a vacuum breaker and he had only been working at the facility for approximately three weeks. 415.29(d)

Plan of Correction: ApprovedJune 2, 2017

I. The following actions were accomplished for the residents identified in the sample:
The hose for the hopper sink, located in the soiled utility room on the 3rd floor, that was identified that the hose/wand and water pipe did not have vacuum breakers installed on them was corrected by replacing the sink faucet that has a vacuum breaker.
II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
All residents have the potential to be affected by this practice.
All hopper sinks in the facility were checked to ensure that the hose/wand and water pipe did have vacuum breakers installed on them
III. The following system changes will be implemented to assure continuing compliance with
regulations:
Maintenance staff re-educated by the Director of Maintenance on ensuring that the hopper sinks were operating correctly and had vacuum breakers installed.
IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
Monthly audits by the Director of Maintenance to be conducted on all hoppers to ensure they are properly operating.
The results of these monthly audits will be reported to the QA Committee Monthly. Frequency of on-going audits will be determined by the QA Committee based on audit results.
Completion Date: 7/01/17
Responsibility: Director of Maintenance/Designee

FF10 483.60(i)(1)-(3):FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY

REGULATION: (i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 9, 2017
Corrected date: July 1, 2017

Citation Details

Based on observations and interview conducted during the Standard survey completed on 5/9/17, the facility did not store, prepare, distribute, and serve food under sanitary conditions. Issues included: ready for use pots, pans, scoops, tongs, spoons, whisks, pitchers, and bowls that were stacked or stored together wet and soiled with greasy white and brown colored substances, and aluminum foil that was adhered to the pans. The shelving, where clean ready-to-use pots and pans were stored, was soiled with black, brown, tan, and white colored food debris and crumbs. The wall behind the oven was deteriorated, was not made of a non-porous material and was not an easily cleanable surface. The floor below the wall was soiled with pieces of gypsum board and dust. This affected one of one First Floor Main Kitchen. The findings are: 1. Observation on the First Floor, in the Main Kitchen, on 5/3/17 at approximately 9:32 AM revealed the following: - 17 pots and pans were stacked together wet on the clean pot and pan rack and water was observed dripping from the pans when the surveyor pulled the pans apart. Seven of the pots and pans were soiled with brown, tan, and white colored greasy substances and two pans still had pieces of aluminum foil attached to them. - Four of the shelves on the clean pot and pan rack, were covered with sheets of aluminum foil that was soiled with black, brown, tan, and white colored food debris and crumbs. - Two slotted spoons, hung from a rack, were greasy to the touch and soiled with a greasy white colored substance. - Two ladles, hung from a rack, were soiled with crusty white and tan colored substances. - Two whisks, hung from a rack, were soiled with a crusty green colored substance. - Two pairs of tongs, hung from a rack, were greasy to the touch and soiled with a greasy tan colored substance. - Seven maroon colored bowls, were stacked together wet on a shelf. Two of the seven bowls were soiled with a wet white colored substance. The bowls were stored on the shelf with at least eight other clean, dry bowls. - Four, cleaned and sanitized pitchers, were stored upright on a shelf, with their lids on and not able to air dry after being sanitized. Each pitcher had greater than one quarter of an inch of water in them. - One approximate 12 inch wide frying pan was soiled with a crusty brown substance. The frying pan was stored stacked on top of three other clean fry pans. - Seven scoops were stored in a drawer, still wet. Four of the seven scoops were soiled with greasy wet, brown and tan colored substances. The seven scoops were stored in the same drawer with at least ten other cleaned and dry scoops. - Two slotted spoons were stored in a drawer, still wet, with clean, dry, metal and plastic spatulas and other clean dry slotted spoons. - An approximated four foot long, by two foot wide, area of the wall behind the oven was deteriorated and missing gypsum board and ceramic tiles. Wooden wall support studs in the wall were exposed due to the missing gypsum board and tiles. The wooden studs were also deteriorated. An approximate two foot long, by two inch wide area of the floor behind the oven was soiled with pieces of the deteriorated gypsum board and dust, that had fallen off of the deteriorated wall. - Interview with the Cook at the time of the above observations, revealed the pots, pans, scoops, tongs, spoons, whisks, pitchers, and bowls were ready for use. - Interview with the Food Service Director on 5/4/17 at approximately 8:40 AM revealed the aluminum foil was put on the shelves of the clean pot and pan rack during the beginning of (MONTH) (YEAR) because the metal shelves were not in good condition and she did not want to store the clean pots and pans directly on the deteriorated shelves. Further interview with the Food Service Director at this time revealed the wall behind the stove started deteriorating a couple of months ago. 415.14(h) New York State Sanitary Code Subpart 14-1 14-1.110(b) 14-1.110(d) 14-1.110(e) 14-1.116 14-1.171(a) 14-1.171(b)

Plan of Correction: ApprovedJune 5, 2017

I. The following actions were accomplished for the residents identified in the sample:
17 pots and pans that were stacked together wet on on the clean pot and pan rack and water was observed dripping from the pans apart. Seven of the pots and pans were soiled with brown, tan, and white colored greasy substances and two pans still had aluminum foil attached to them, all pots and pans were immediately washed and hung to dry correctly.
Four of the shelves on the clean pot and pan rack were covered with sheets of aluminum foil that was soiled with debris and crumbs, the metal pot and pan rack was replaced with a plastic pot and pan rack.
Two slotted spoons, hung from a rack, greasy to the touch and soiled with crusty white colored substance were immediately washed.
Two ladles hung from a rack, that were soiled with a crusty green colored substance were immediately washed.
Two whisks, hung from a rack, were soiled with crusty green colored substance were immediately washed.
Two pairs of tongs, hung from a rack, that were greasy to the touch and soiled with a greasy tan colored substance were immediately washed.
Seven maroon colored bowls, were stacked together wet on a shelf, and two of the seven bowls were soiled with a wet white colored substance were immediately washed and left to dry.
Four, cleaned and sanitized pitchers were stored upright on the shelf with lids on no able to air dry after being sanitized, were immediately re-sanitized and left with the lids off to air dry.
One approximate 12 inch wide frying pan was soiled with a crusty brown substance and stored stacked on top of three other clean fry pans- all the fry pans were immediately washed and dried prior to being stored.
Seven scoops were stored in a drawer still wet, four of the seven scoops were soiled with greasy wet, brown and tan colored substance, stored in the same drawer with 10 other cleaned and dry scoops, all scoops were immediately washed and dried prior to being put away.
Two slotted spoons that were stored in a drawer still wet, with clean, dry, metal and plastic spatulas and other clean dry slotted spoons- all of the utensils in the drawer were immediately washed and dried prior to being put away.
An approximated four foot long, by two foot wide, area of the wall behind the oven was deteriorated and missing gypsum board and ceramic tiles. Wooden wall studs were also deteriorated. The wall behind the oven was repaired by replacing wooden studs, wall board and tile.
II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
All residents have the potential to be affected by this practice.

All pots, pans and utensils were inspected to ensure they were clean and free of any debris and properly dried.

III. The following system changes will be implemented to assure continuing compliance with regulations:
The Director of Food Service to be re-educated by the Administrator on the facility policy and procedure for cleaning pots, pans and utensils and proper storage of these items. The Director of Food Service will then re-educate all dietary staff on this policy and procedure.
IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
Random daily audits will be conducted by the Director of Food Service of pots, pans and utensils to ensure cleanliness and proper storage will occur for 2 weeks, then weekly audits for 4 weeks, followed by monthly audits for 4 months.

Results of these audits will be reported to the QA Committee Monthly. Frequency of on-going audits will be determined by the QA Committee based on audit results.
Completion Date: 7/01/17
Responsibility: Food Service Director














FF10 483.10(i)(2):HOUSEKEEPING & MAINTENANCE SERVICES

REGULATION: (i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: May 9, 2017
Corrected date: July 1, 2017

Citation Details

Based on observation, record review and interview conducted during a Standard survey completed on 5/9/17, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Two (Units 1, 2) of two units observed for environment had issues with unlabeled urinals in shared bathrooms, a labeled urinal dated 12/29 that did not belong to any of the residents in a shared bathroom, graduated urine measuring cylinders on the floor next to the toilet that contained urine, unlabeled compression stockings hung on toilet grab bars in a shared bathroom, and paint peeling on a resident's wall. The findings are: 1. Intermittent observations on 5/3/17 between 10:00 AM to12:00 PM revealed the following: Room #110 - area of peeling paint approximately one square foot above the resident's night stand. Room #112 - two pairs of unlabeled compression stockings hanging on toilet grab bars in a shared connected bathroom that is shared by four people. Room #213 - unlabeled urinal hanging on a toilet bar in a shared connected bathroom. Room #214 - unlabeled urinal hanging on the toilet grab bar and another urinal labeled with the initials NV with a date of 12/29 on it in a shared connected bathroom. None of the residents in room #214 or room #212 have those initials. Intermittent observations on 5/4/17 between 9:00 AM and 10:00 AM revealed the following: Room #115 - two graduated urine measuring cylinders on the floor next to the toilet in a shared connected bathroom. Intermittent observations on 5/5/17 between 6:00 AM and 10:00 AM revealed the following: Room #110 - area of peeling paint approximately one square foot above the resident's night stand. Room #112 - two pairs of unlabeled compression stockings hanging on toilet grab bars in a shared connected bathroom that is shared by four people. Room #115 - one graduated urine measuring cylinder on the floor next to the toilet in a shared connected bathroom with a scant amount of urine in it. Room #213 - unlabeled urinal hanging on a toilet bar in a shared connected bathroom. Room #214 - unlabeled urinal hanging on the toilet grab bar and another urinal labeled with the initials NV with a date of 12/29 on it in a shared connected bathroom. None of the residents in room #214 or room #212 have those initials. During an interview on 5/3/17 at approximately 10:35 AM, Resident A revealed that the the peeling paint has been there for a while and it looks kind of ugly. When asked on 5/5/17 at approximately 6:45 AM if the peeling paint bothered Resident A the resident stated, Yes, and it doesn't look good. During an interview on 5/5/17 at approximately 9:50 AM, Resident B did not know who the stockings belonged to in the bathroom and stated they might be mine but I'm not sure. Interview with Registered Nurse (RN) #1 on 5/5/17 at approximately 10:10 AM revealed that the aides are responsible for labeling, cleaning, and storing the resident's equipment. RN #1 stated that if there is a problem he expects his staff to fix it if they are able and to report any repairs that need to be done to the Maintenance department. He stated that there is a Maintenance Log that Maintenance checks. RN #1 stated that he will put the room issues in the Maintenance Log and get them to repair it. Interview with the Maintenance Director on 5/5/17 at approximately 10:30 AM revealed that environmental rounds are done once a month and he was not aware of the issues in Room #110. He stated he will address the issue with the room as soon as possible. Interview with RN #2 on 5/5/17 at approximately 11:10 AM revealed that she expects her staff to label and store the urinals properly and to throw out any resident equipment if the resident is no longer there. RN #2 stated that she expects her staff to throw out the unlabeled resident care equipment in a shared bathroom because that's disgusting. During an interview on 5/5/17 at approximately 11:15 AM, the CNA revealed he was trained that after you measure the urine in the urinal, you dump it out in toilet, rinse it and place it in night stand. In addition, it should be labeled with name of the resident. Review of the facility policy entitled Storage of Items in Resident Rooms dated 1/1999 revealed that no items will be stored on floors in the resident rooms and that graduated cylinders shall be clean and placed on the bottom shelf of the bedside stand. 415.5(h)(2)

Plan of Correction: ApprovedJune 6, 2017

I. The following actions were accomplished for the residents identified in the sample:
Room #110- area of peeling paint has been re-painted.
Room #112- two pairs of unlabeled compression stockings were discarded, new compression stockings were distributed and labeled.
Room #213- unlabeled urinal was removed and replaced with a new urinal that was labeled.
Room #214- unlabeled urinal was removed and discarded.
Room #115- two graduated urine measuring cylinders on the floor next to the toilet were discarded.
II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
All residents have the potential to be affected by this practice.
100% audit will be completed for all resident rooms to identify any peeling paint, as well as any unlabeled items.
III. The following system changes will be implemented to assure continuing compliance with regulations:
Nursing and Environmental Services staff will be re-educated on labeling items, not leaving items on the floor, and removing items when someone is discharged . All disicplines will also be re-educated on reporting any repairs in the Maintenance Log.
IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
Environmental Round Audits by the Director of Maintenance to identify any areas that need to be re-painted to be completed weekly for 4 weeks of 10 rooms, then every 2 weeks for 4 weeks of 10 rooms, and monthly thereafter of 10 rooms.
Environmental Round Audits by the Director of Nursing to identify any unlabeled items to be completed weekly for 4 weeks of 10 rooms, then every 2 weeks for 4 weeks of 10 rooms and monthly thereafter of 10 rooms.
Results of these audits will be reported to the QA Committee Monthly. Frequency of on-going audits will be determined by the QA Committee based on audit results.
Completion Date: 7/01/17
Responsibility: Director of Maintenance and Director of Nursing

FF10 483.12(a)(3)(4)(c)(1)-(4):INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS

REGULATION: 483.12(a) The facility must- (3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: May 9, 2017
Corrected date: July 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the Standard survey completed on 5/9/17, the facility did not ensure that the State nurse aide registry was checked for new employees to identify potential findings concerning abuse, neglect, exploitation, mistreatment of [REDACTED]. One of five employees hired in the last four months lacked verification with the New York State Nurse Aide Registry prior to employment. The finding is: 1. Review of the employee file for Employee #1, a Housekeeping Aide, revealed the employee was hired on 1/5/17 and the file did not contain a Nurse Aide Registry Verification Report for the employee. Review of weekly Supervisory Tracking for Temporary Employees forms for Employee #1 on 5/4/17 revealed the employee had worked at the facility from the week of 1/9/17 through 5/4/17. Interview with the Business Office Manager (Authorized Person) on 5/4/17 at approximately 11:23 AM revealed Employee #1 was currently employed by the facility as a Housekeeping Aide. The interview revealed the Business Office Manager conducted a Nurse Aide Registry Verification Report for Employee #1 prior to the employee being hired but had mistakenly pressed the wrong print tab on her computer screen resulting in two blank sheets of paper being printed instead of a Nurse Aide Registry Verification Report. Review of the two pieces of paper from Employee #1's file dated 12/30/16 revealed they contained no information about Employee #1. Further interview with the Business Office Manager at this time revealed the facility did not have a detailed policy and procedure for how Nurse Aide Registry Verification Reports shall be conducted for employees and that she conducts Nurse Aide Registry Verification Reports for the employees prior to their employment. Continued interview revealed that all Housekeeping Aides work throughout the facility. Review of a New Hire Notice on 5/5/17 revealed Employee #1's hire date was 1/5/17. Review of Time Detail logs on 5/5/17 revealed Employee #1 worked at the facility for 79 days between 1/9/17 and 5/4/17. Review of an undated Employment Policy and Procedure revealed the Nurse Aide Registry Verification Report is to be completed prior to any applicant interview. 415.4(b)(1)(ii)(b)

Plan of Correction: ApprovedJune 5, 2017

I. The following actions were accomplished for the residents identified in the sample:
Employee #1- a Nurse Aide Registry Verification Report has been printed and placed in the employee?s personnel file.

II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
All residents have the potential to be affected by this practice.

100% audit was completed by the Administrator to ensure all new hires within the last 6 months have a printed Nurse Aide Registry Verification Report in their personnel file.
III. The following system changes will be implemented to assure continuing compliance with regulations:
The Human Resource Manager was re-educated on ensuring the correct print tab on the computer screen is selected when printing the Nurse Aide Registry Verification Report.
IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
Audits for all new hires personnel files, to ensure the Nurse Aide Registry Verification Report printed and in the file will be conducted for 3 months by the Administrator.
Results of these audits will be presented to the QA Committee Monthly. Frequency of on-going audits will be determined by the QA Committee based on audit results.

Completion Date: 7/01/17
Responsibility: Administrator

FF10 483.10(d)(3)(g)(1)(4)(5)(13)(16)-(18):NOTICE OF RIGHTS, RULES, SERVICES, CHARGES

REGULATION: (d)(3) The facility must ensure that each resident remains informed of the name, specialty, and way of contacting the physician and other primary care professionals responsible for his or her care. §483.10(g) Information and Communication. (1) The resident has the right to be informed of his or her rights and of all rules and regulations governing resident conduct and responsibilities during his or her stay in the facility. (g)(4) The resident has the right to receive notices orally (meaning spoken) and in writing (including Braille) in a format and a language he or she understands, including: (i) Required notices as specified in this section. The facility must furnish to each resident a written description of legal rights which includes - (A) A description of the manner of protecting personal funds, under paragraph (f)(10) of this section; (B) A description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment of resources under section 1924(c) of the Social Security Act. (C) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State regulatory and informational agencies, resident advocacy groups such as the State Survey Agency, the State licensure office, the State Long-Term Care Ombudsman program, the protection and advocacy agency, adult protective services where state law provides for jurisdiction in long-term care facilities, the local contact agency for information about returning to the community and the Medicaid Fraud Control Unit; and (D) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community. (ii) Information and contact information for State and local advocacy organizations including but not limited to the State Survey Agency, the State Long-Term Care Ombudsman program (established under section 712 of the Older Americans Act of 1965, as amended 2016 (42 U.S.C. 3001 et seq) and the protection and advocacy system (as designated by the state, and as established under the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15001 et seq.) [§483.10(g)(4)(ii) will be implemented beginning November 28, 2017 (Phase 2)] (iii) Information regarding Medicare and Medicaid eligibility and coverage; [§483.10(g)(4)(iii) will be implemented beginning November 28, 2017 (Phase 2)] (iv) Contact information for the Aging and Disability Resource Center (established under Section 202(a)(20)(B)(iii) of the Older Americans Act); or other No Wrong Door Program; [§483.10(g)(4)(iv) will be implemented beginning November 28, 2017 (Phase 2)] (v) Contact information for the Medicaid Fraud Control Unit; and [§483.10(g)(4)(v) will be implemented beginning November 28, 2017 (Phase 2)] (vi) Information and contact information for filing grievances or complaints concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community. (g)(5) The facility must post, in a form and manner accessible and understandable to residents, resident representatives: (i) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit; and (ii) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, and non-compliance with the advanced directives requirements (42 CFR part 489 subpart I) and requests for information regarding returning to the community. (g)(13) The facility must display in the facility written information, and provide to residents and applicants for admission, oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. (g)(16) The facility must provide a notice of rights and services to the resident prior to or upon admission and during the resident?s stay. (i) The facility must inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. (ii) The facility must also provide the resident with the State-developed notice of Medicaid rights and obligations, if any. (iii) Receipt of such information, and any amendments to it, must be acknowledged in writing; (g)(17) The facility must-- (i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of- (A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and (ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in paragraphs (g)(17)(i)(A) and (B) of this section. (g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident?s stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility?s per diem rate. (i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible. (ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change. (iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility?s per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements. (iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident?s date of discharge from the facility. v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.

Scope: Isolated
Severity: Potential to cause minimal harm
Citation date: May 9, 2017
Corrected date: N/A

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 5/9/17, the facility did not ensure the Notice of Medicare Non-Coverage (NOMNC) was delivered to the beneficiary 48 hours prior to termination of Medicare benefits. One (Resident #20) of three residents reviewed for notification of Medicare non-coverage did not receive a NOMNC in a timely manner. 1. Resident #20 was admitted to the facility 12/6/16 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 12/13/16 revealed the resident is cognitively intact, is understood, and understands. Review of the facility Clinical Census revealed Medicare A was Primary Payer for Resident #20 from 12/6/16 through 12/19/16. Review of the Clinical - MDS screen shot revealed Resident #20 was discharged Return Not Anticipated on 12/20/16. Review of an undated NOMNC, signed by the Director of Nursing (DON) and the Business Office Manager revealed the Notice documented the following: - The Effective Date Coverage of Your Current Skilled Nursing Facility Services Will End: (MONTH) 20, (YEAR) - Spoke to (Resident #20) by phone on 12/21/16 and explained letter, then put a copy in the mail for her to sign and return. Interview with the Business Office Manager on 5/8/17 at approximately 8:13 AM revealed I usually give the NOMNC on the day of discharge if I know they (residents) are leaving. If I don't know they are leaving then I usually end up mailing it the day after discharge. The Business Office manager stated I honestly don't know the rules on the letters, I have not been trained on them (the letters). I think they (the residents) are supposed to get the letter 48 hours prior. Interview with the DON on 5/8/17 at approximately 9:18 AM revealed I don't know really know why I sign the NOMNC, I guess just for confirmation. The NOMNC should be delivered on the day of discharge. The DON stated I don't think there is a (facility) policy for the NOMNC, we follow the CMS (Centers for Medicare & Medicaid Services)rules. Review of Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) revealed The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. 415.3(g)(2)(iii)

Plan of Correction: ApprovedJune 2, 2017

A plan of correction is not required for deficiencies at scope and severity level A. The facility remains responsible to expeditiously correct all deficiencies and to ensure measures are in place to maintain compliance. Please submit this information to the Department to acknowledge this message.

Standard Life Safety Code Citations

K307 NFPA 101:BUILDING CONSTRUCTION TYPE AND HEIGHT

REGULATION: Building Construction Type and Height 2012 EXISTING Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7 19.1.6.4, 19.1.6.5 Construction Type 1 I (442), I (332), II (222) Any number of stories non-sprinklered and sprinklered 2 II (111) One story non-sprinklered Maximum 3 stories sprinklered 3 II (000) Not allowed non-sprinklered 4 III (211) Maximum 2 stories sprinklered 5 IV (2HH) 6 V (111) 7 III (200) Not allowed non-sprinklered 8 V (000) Maximum 1 story sprinklered Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 6, 2017
Corrected date: August 3, 2017

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 5/9/17, structural components of the building were not properly protected from fire. Issues include the structural support web truss system, located above the lay-in ceiling assembly, was not protected to meet minimum fire rated building construction type II (111). This affected one (Third Floor) of three resident use floors. The findings are: 1. a) Observation on 5/3/17 from approximately 9:32 AM until 3:30 PM revealed the ceiling assembly located throughout the Third Floor, was comprised of lay-in ceiling tiles and the building appeared to be fully sprinklered. Observation above the ceiling tiles on the Third Floor on 5/3/17 at approximately 11:31 AM revealed unprotected structural steel web roof truss supports in the air handler room located next to Resident room [ROOM NUMBER]. Observations above the ceiling tiles on the Third Floor on 5/4/17 from approximately 8:40 AM to 10:15 AM revealed that metal clips were observed to be lying on the tops of ceiling tiles. The ceiling tiles were not clipped in place and the ceiling tiles had no information on them regarding their fire resistance rating. Observations above the ceiling tiles on the Third Floor, in the corridor, on 5/4/17 at approximately 8:40 AM revealed unprotected structural steel web roof truss supports near Resident Rooms #201, 202, 203, and 204. Observation above the ceiling tiles on the Third Floor, on 5/4/17 at approximately 9:24 AM revealed unprotected structural steel web roof truss supports in Resident Rooms #203, 204, and 205. Observation above the ceiling tiles on the Third Floor, in the corridor, on 5/4/17 at approximately 9:45 AM revealed unprotected structural steel web roof truss supports near Resident Rooms #205, 206, and 207. Observations above the ceiling tiles on the Third Floor, on 5/4/17 at approximately 10:05 AM revealed unprotected structural steel web roof truss supports above the ceiling tiles in Resident Rooms #208, 210, 212, 214, 216, and 218. Observations above the ceiling tiles on the Third Floor, in the corridor, on 5/4/17 at approximately 10:15 AM revealed unprotected structural steel web roof truss supports near Resident Rooms #215 and 217. Interview with the Maintenance Supervisor on 5/4/17 at approximately 10:20 AM revealed he did not have any documentation for the fire resistance rating of the Third Floor lay-in ceiling tiles and the ceiling grid work and wiring assembly, that held the ceiling tiles in place. Further interview with the Maintenance Supervisor at this time revealed he had only been working at the facility for approximately three weeks. Observations of the interior and exterior of the building and a review of the measurements of the perimeter of the building (that were provided by the Building Superintendent on 9/8/11) on 5/3/17 at approximately 2:37 PM confirmed that the floor of the building's lowest story (current Basement/ actual First floor) was level with or above the finished grade on the exterior wall line for greater than 50 percent of the building's perimeter. Per the 2012 edition of NFPA 101 Life Safety Code (LSC); 19.1.6 Minimum Construction Requirements, 19.1.6.1, the number of stories shall be counted starting with the primary level of exit discharge and ending with the highest occupiable level. For the purposes of 19.1.6, the primary level of exit/ discharge of a building shall be the lowest story whose floor is level with or above finished grade on the exterior wall line for 50 percent or more of its perimeter. Building levels below the primary level shall not be counted as a story. Therefore, this building is considered to be a three-story building. Also, per the 2012 edition of NFPA 101 Life Safety Code, a three-story building which is fully sprinklered is required to have at least a one hour fire resistive rating protecting structural elements such as steel web truss supports. Therefore, the facility does not meet the construction requirements per the 2012 edition of NFPA 101 Life Safety Code, 19.1.6.2, Minimum Construction Requirements. Interview with the Administrator on 5/8/17 at approximately 9:04 AM revealed that the facility did not have any documentation for the fire resistance rating of the Third Floor lay-in ceiling tiles, and the grid work and wiring assembly, that held the ceiling tiles in place. Further interview with the Administrator at this time revealed a Fire Safety Evaluation System (FSES) was conducted on the facility on 6/28/12 and no other FSES had been conducted on the building since that time. A Fire Safety Evaluation System (FSES) was conducted at the facility on 6/28/12. The 6/28/12 FSES was conducted using the 1998 edition of NFPA 101A, Guide on Alternative Approaches to Life Safety. CMS has since adopted (effective (MONTH) 5, (YEAR)) the 2012 NFPA Life Safety Code and 2012 NFPA 99 Health Care Facility Code with survey enforcement starting on (MONTH) 1, (YEAR). Facilities must now use the 2013 edition of NFPA 101A to achieve compliance with the Medicare and Medicaid fire safety requirements. Per the Centers for Medicare & Medicaid Services Survey and Certification letter, Ref: S&C: 17-15-LSC dated (MONTH) 16, (YEAR): Fire Safety Requirements: The Centers for Medicare & Medicaid Services (CMS) has adopted the 2012 Life Safety Code (LSC) and the 2012 Health Care Facilities Code (HCFC) through regulation (see 81 FR , 5/4/16), effective (MONTH) 5, (YEAR). If the FSES is being used to demonstrate compliance with the fire safety requirements, the version of the FSES for Health Care Occupancies found in the 2013 edition of the Guide on Alternative Approaches to Life Safety, NFPA 101A must be used. A facility that achieves a passing score on the 2013 edition of the FSES will be considered to meet the fire safety requirements for certification and recertification with the Medicare and Medicaid programs. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 4.6.7, 4.6.7.1(6), 8.2, 8.2.1, 8.2.1.1, 8.2.1.2, 19.1.1.4, 19.1.1.4.1, 19.1.6, 19.1.6.1, 19.3.5, 19.3.5.1 2012 NFPA 220 Standard on Types of Building Construction: 4.1, 4.1.1 Centers for Medicare & Medicaid Services Survey and Certification letter, Ref: S&C: 17-15-LSC dated (MONTH) 16, (YEAR): Fire Safety Requirements**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during a Life Safety Code Post Survey Revisit #1, completed on 7/6/17, structural components of the building were not properly protected from fire. Issues include the structural support web truss system, located above the lay-in ceiling assembly, was not protected to meet minimum fire rated building construction type II (111). This is a Continuing Deficiency from the Life Safety Code survey completed on 5/9/17 that affected one (Third Floor) of three resident use floors. The findings are: 1. Interview with the Maintenance Supervisor on 7/6/17 at approximately 11:07 AM revealed there has been no physical changes to the structural steel web roof truss supports on the Third Floor of the facility, and the facility has submitted a request for a Time Limited Waiver through (MONTH) 2020, for correction of this deficiency. Observations during the Life Safety Survey completed on 5/3/17 identified unprotected structural steel web roof truss supports above the lay in ceiling assembly, on the Third Floor, in the following locations: - The air handler room located next to Resident room [ROOM NUMBER]. - The corridor, near Resident Rooms #201, 202, 203, and 204. - Resident Rooms #203, 204, and 205. - The corridor near Resident Rooms #205, 206, and 207. - Resident Rooms #208, 210, 212, 214, 216, and 218. - The corridor near Resident Rooms #215 and 217. Observations of the interior and exterior of the building on 7/6/17 revealed that the floor of the building's lowest story (current Basement/ actual First Floor) was level with or above the finished grade on the exterior wall line for greater than 50 percent of the building's perimeter. Per the 2012 edition of NFPA 101 Life Safety Code (LSC); 19.1.6 Minimum Construction Requirements, 19.1.6.1, the number of stories shall be counted starting with the primary level of exit discharge and ending with the highest occupiable level. For the purposes of 19.1.6, the primary level of exit/ discharge of a building shall be the lowest story whose floor is level with or above finished grade on the exterior wall line for 50 percent or more of its perimeter. Building levels below the primary level shall not be counted as a story. Therefore, this building is classified as a three-story building. Also, per the 2012 edition of NFPA 101 Life Safety Code, a three-story building which is fully sprinklered is required to have at least a one hour fire resistive rating protecting structural elements such as steel web truss supports. Therefore, the facility does not meet the construction requirements per the 2012 edition of NFPA 101 Life Safety Code, 19.1.6.2, Minimum Construction Requirements. A Fire Safety Evaluation System (FSES) was conducted at the facility on 6/28/12. The 6/28/12 FSES was conducted using the 1998 edition of NFPA 101A, Guide on Alternative Approaches to Life Safety. CMS has since adopted (effective (MONTH) 5, (YEAR)) the 2012 NFPA Life Safety Code and 2012 NFPA 99 Health Care Facility Code with survey enforcement starting on (MONTH) 1, (YEAR). Facilities must now use the 2013 edition of NFPA 101A to achieve compliance with the Medicare and Medicaid fire safety requirements. Per the Centers for Medicare & Medicaid Services Survey and Certification letter, Ref: S&C: 17-15-LSC dated (MONTH) 16, (YEAR): Fire Safety Requirements: The Centers for Medicare & Medicaid Services (CMS) has adopted the 2012 Life Safety Code (LSC) and the 2012 Health Care Facilities Code (HCFC) through regulation (see 81 FR , 5/4/16), effective (MONTH) 5, (YEAR). If the FSES is being used to demonstrate compliance with the fire safety requirements, the version of the FSES for Health Care Occupancies found in the 2013 edition of the Guide on Alternative Approaches to Life Safety, NFPA 101A must be used. A facility that achieves a passing score on the 2013 edition of the FSES will be considered to meet the fire safety requirements for certification and recertification with the Medicare and Medicaid programs. A review of DOH documents revealed this facility applied for a Time Limited Waiver on 7/3/17 with an expiration date of 7/1/20. This waiver has been approved at the New York State level and was sent to CMS on 7/7/17, where it is under review. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 4.6.7, 4.6.7.1(6), 8.2, 8.2.1, 8.2.1.1, 8.2.1.2, 19.1.1.4, 19.1.1.4.1, 19.1.6, 19.1.6.1, 19.3.5, 19.3.5.1 2012 NFPA 220 Standard on Types of Building Construction: 4.1, 4.1.1 Centers for Medicare & Medicaid Services Survey and Certification letter, Ref: S&C: 17-15-LSC dated (MONTH) 16, (YEAR): Fire Safety Requirements

Plan of Correction: ApprovedJuly 24, 2017

The facility will enter a contract with an outside agency to conduct a FSES to show compliance with the 2012 edition of the Life Safety Code, will be done so using the 2013 edition of the NFPA101A, as per CMS. The facility will begin the process of applying for a Time Limited Waiver for up to 5 years (per CMS) to make physical alterations to the building to achieve compliance in the event the FSES does not achieve a passing score.
The maintenance staff and QA committee will be educated on the requirements of the FSES by the Administrator.
The FSES review will include a full facility audit for any other locations that may have unprotected steel supports.
The Director of Maintenance will review the FSES annually to assure that it is in effect. Any changes to the building that would affect the continuation of the FSES will be brought to the QA committee for review and further recommendations.
Responsible Party: Director of Maintenance

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 9, 2017
Corrected date: July 1, 2017

Citation Details

Based on observation and interview during a Life Safety Code survey completed on 5/9/17, a corridor door that protected a hazardous area was not properly maintained. Issues included a corridor door to a hazardous area that was being held open by a device that was not arranged to automatically close the door upon activation of the required manual fire alarm system, local smoke detectors, automatic sprinkler system, or loss of power. This affected one (Third Floor) of three resident use floors. The findings are: 1. Observation on the Third Floor, behind the nurse's station, on 5/3/17 at approximately 11:15 AM revealed the door to the medication storage/medical supply room was in a fully open position. Further observation at this time revealed the door was being held open by a magnetic hold open device that was not arranged to automatically close the door upon activation of the required manual fire alarm system, local smoke detectors, automatic sprinkler system or loss of power. Further observation revealed there was no self-closing device installed on the door. Continued observation at this time revealed the room was greater than 50 square feet in size and it was being used to store medication and medical supplies. Interview with the Maintenance Supervisor at the time of the observation revealed he was not aware the door was equipped with this type of hold open device and he had only been working at the facility for approximately three weeks. 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: ApprovedJune 2, 2017

I. The following actions were accomplished for the residents identified in the sample:
Magnetic hold open device on the door to the medication room that was holding the door in a fully open position was immediately removed.
II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
All residents have the potential to be affected by this practice.
100% audit was conducted of all doors in the building to check for the magnetic hold open device by the Director of Maintenance.
III. The following system changes will be implemented to assure continuing compliance with regulations:
Magnetic hold open devices for doors will not be used in the future.
IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
Quarterly audits by the Director of Maintenace for 1yr for all doors in the facility. The results of these audits will be reported to the QA Committee Monthly. Frequency of on-going audits will be determined by the QA Committee based on audit results.
Completion Date: 7/01/17
Responsibility: Director of Maintenance/Designee

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: May 9, 2017
Corrected date: July 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations during a Life Safety Code survey completed on 5/9/17, electrical equipment was not properly maintained. Issues included electrical adapters and extension cords, being used to supply a permanent supply of power to electrical appliances. This affected two (First and Second Floors) of three resident use floors. The findings are: 1. Observation on the First Floor on 5/3/17 at approximately 12:24 PM revealed a three-outlet electrical adapter was supplying power to a computer's modem and monitor located in the Assistant Director of Nursing's office/ In-service room. 2. Observation on the First Floor on 5/3/17 at approximately 12:36 PM revealed a three-outlet electrical adapter was supplying power to a computer's modem and monitor located in the Dietary office. 3. Observation on the First Floor on 5/3/17 at approximately 12:40 PM revealed an extension cord was supplying power to computer's modem and monitor in the Dietary office. 4. Observation on the First Floor on 5/3/17 at approximately 3:09 PM revealed a six-outlet electrical adapter was supplying power to a computer's modem and monitor located in the laundry clean linen/ folding room. 5. Observation on the Second Floor on 5/5/17 at approximately 12:40 PM revealed a power strip that was plugged into two-pronged electrical adapter was being used to supply power to a television, a cable television converter box, and an alarm clock in Resident room [ROOM NUMBER]. Further observation at this time revealed the power strip's flexible power cord had a three-pronged plug that was plugged into the two two-pronged electrical adapter. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 10.2.3.6, 10.2.4, 10.2.4.1, 10.2.4.2, 10.2.4.2.1 2011 NFPA 70: 400.8(1)

Plan of Correction: ApprovedJune 5, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. The following actions were accomplished for the residents identified in the sample:
The three -outlet electrical adapter from the Assistant Director of Nursing?s Office/In-Service room was removed and replaced with a 1363 UL power strip.
The three-outlet electrical adapter that was supplying power to a computer?s monitor in dietary was removed and replaced with a 1363 UL power strip.
An extension cord that was supplying power to a computer?s modem and monitor in the dietary office was removed and replaced with a 1363 UL power strip.
A six-outlet electrical adapter that was supplying power to a computer?s modem and monitor located in the laundry clean linen/folding room was replaced with a 1363 UL power strip.
room [ROOM NUMBER]- the power strip that was plugged into a two-pronged electrical adapter and supplying power to a television, cable converter box, and an alarm clock was removed and replaced with a 1363 UL power strip.
II. The following corrective actions will be implemented :
All residents have the potential to be affected by this practice.
A 100% audit of the facility was conducted by the Director of Maintenance to identify any other locations of unapproved power strips/extension cords.
III. The following system changes will be implemented to assure continuing compliance with regulations:
Monthly Environmental Rounds done by the Director of Maintenance will now include identifying any unapproved power strips/extension cords.
IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
Director of Maintenance will report findings of any unapproved power strips/extension cords from Environmental Rounds to the QA Committee Monthly. Frequency of the on-going audits will be determined by the QA Committee based on audit results.
Completion Date: 7/01/17
Responsibility: Director of Maintenance



K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 9, 2017
Corrected date: July 1, 2017

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 5/9/17, the facility did not develop a program for the maintenance of electrical equipment per manufacturer's recommendations and did not maintain a written record of maintenance and testing of all patient care-related electrical equipment. Issues included, the facility did not have documentation for the inspection, testing, and maintenance of oxygen concentrators and electric beds. This affected two (Second and Third Floors) of three resident use floors. The findings are: 1. Interview with the Administrator on 5/8/17 at approximately 9:09 AM revealed the previous Maintenance Supervisor inspected, tested , and maintained the facility's electrical equipment including oxygen concentrators and electric beds, but he was not sure if the facility had documentation showing when the equipment had been inspected and tested . Review of the Policy and Procedure for Maintenance of Electrical Equipment including test and intervals for patient care equipment on 5/8/17 revealed the flowing under the heading Policy; All facility electrical equipment including patient care equipment will be maintained in accordance with manufactures instructions. Records of test and maintenance will be kept at the facility. Under the heading Responsibility: 1. Maintenance Director/ Designee 2. Outside vender when appropriate Under the heading Procedure: 1. Manuals and user guides will be maintained in one location to ensure they are readily available. 2. Maintenance Director/ designee will keep manuals up to date. 3. Maintenance Director/ designee will keep a record of compliance for testing and maintenance. Review of the user manual for oxygen concentrator's on 5/8/17 revealed the concentrators should be cleaned and disinfected between patient usage and the following preventative maintenance should be performed at either six month or three year intervals depending on the model: Check oxygen concentration indicator light, clean/ replace cabinet filter, outlet filter, compressor inlet filter, power loss alarm, and check concentrator for external damage or signs that it may require service or repair. Review of use and care manuals for electric beds on 5/8/17 revealed the following should be reviewed every six months to ensure proper functioning of the bed: All moving components, including bed joints, motor clevis joints, casters are self-lubricating and maintenance free, [MEDICATION NAME] run smoothly and quietly through their range, and inspect all attachment points, wires, piston rods, and plugs. Further review of use and care manuals for electric beds on 5/8/17 revealed the following must be inspected at least once a year by a competent person: power cord - no fraying or cuts, bushings, [MEDICATION NAME], motor operation, normal operation over full range, grinding popping and other noises, bent parts, clevis pins and fasteners, retaining rings, cabling no visible wear, caster locking, side rail and latches, head and foot board, inspect all panels, inspect all around, clean dirt and impurities, and paint finish. Interview with the Maintenance Supervisor on 5/8/17 at approximately 9:57 AM revealed he had no inspection, maintenance or testing records for any of the facility's electrical equipment including oxygen concentrators and electric beds that were used on the Second and Third floors of the building. Further interview with the maintenance Supervisor at this time revealed he had only been working at the facility for approximately three weeks. Per the 2012 edition of NFPA 99, Health Care Facilities Code a record shall be maintained of the tests required and associated repairs or modifications. At a minimum, the record shall contain all of the following: (1) Date (2) Unique identification of the equipment tested (3) Indication of which items have met or have failed to meet performance requirements 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 10.5.2, 10.5.2.1, 10.5.2.1.1, 10.5.3, 10.5.3.1.2, 10.5.6, 10.5.6.2, 10.5.6.2.1, 10.5.6.2.2

Plan of Correction: ApprovedJune 5, 2017

I. The following actions were accomplished for the residents identified in the sample:
The facility did not develop a program for maintenance of electrical equipment per manufacturer?s recommendations and did not maintain a written record of maintenance and testing of all patient care-related electrical equipment. Issues included, the facility did not have documentation for the inspection, testing, and maintenance of oxygen concentrators and electric beds.
II. The following corrective actions will be implemented :
All residents have the potential to be affected by this practice.
Facility will maintain records of test and maintenance completed on electrical equipment.
III. The following system changes will be implemented to assure continuing compliance with regulations:
The facility will obtain manufacturers requirements,review the requirements and implement testing/preventative maintenance per the manufacturer's specifications.
Director of Maintenance to complete logs on the maintenance of oxygen concentrators to ensure preventative maintenance is being performed based on the model of the concentrator.
Director of Maintenance to complete logs on the maintenance of the electric beds.
Director of Maintenance to review logs monthly with the Administrator
IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
Director of Maintenance will report any negative findings of the electrical equipment logs to the QA Committee Monthly. Frequency of the on-going audits will be determined by the QA Committee based on audit results.
Completion Date: 7/01/17
Responsibility: Director of Maintenance

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: May 9, 2017
Corrected date: July 1, 2017

Citation Details

Based on interview and record review during a Life Safety Code survey completed on 5/9/17, the emergency generator was not properly maintained. Issues included, the emergency generator was not run under load for at least 30 minutes, 12 times a year(monthly), in 20 to 40 day intervals. This affected one of one emergency generator. The findings are: 1. Record review of Emergency Generator Load Test logs on 5/5/17 revealed the emergency generator was not run under load for at least 30 minutes during the months of July, September, and (MONTH) of (YEAR). Further review of the logs at this time revealed it contained no documentation that the emergency generator had been run for at least 30 minutes under load during (MONTH) of (YEAR). Interview with the Maintenance Supervisor on 5/5/17 at approximately 9:23 AM revealed he was not sure why the emergency generator was not run under load for at least 30 minutes and he had only been working at the facility for approximately three weeks. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 6.4.4, 6.4.4.1, 6.4.4.1.1.3, 6.4.4.1.1.4(A) 2010 NFPA 110: 8.4, 8.4.1

Plan of Correction: ApprovedJune 5, 2017

Fiddler?s Green Manor will ensure the generator is exercised under load for 30 minutes per month in accordance with NFPA 111.

II. The following corrective actions will be implemented :
All residents have the potential to be affected by this practice.
100% audit will be conducted by the Director of Maintenance on monthly generator full load test noting the meter reading at the beginning and end of the test. The duration of the load tests to assure they are at least 30 minutes in duration will be documented on the log sheet noting the meter reading at the beginning and end of the full load test. Immediate action will be taken where deficient practice is identified.
III. The following system changes will be implemented to assure continuing compliance with regulations:
Director of Maintenance and Maintenance staff to be re-educated by the Administrator on proper generator testing and record keeping. New log sheets were developed by the Director of Maintenance for weekly inspections and monthly full load tests. Load test reports will be submitted to the Administrator monthly.
IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
Director of Maintenance will conduct monthly audits for 6 months on the generator to assure that weekly inspections and monthly full load tests of 30 minutes duration are conducted and properly recorded. The results of these audits will be reported to the QA Committee Monthly. Frequency of on-going audits will be determined by the QA Committee based on audit results.
Completion Date: 7/01/17
Responsibility: Director of Maintenance

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: May 9, 2017
Corrected date: July 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations during a Life Safety Code survey completed on 5/9/17, electrical equipment was not properly maintained. Issues included electrical junction boxes that were open and uncovered or had openings in them that were not being used for electrical purposes, and the ground prong (a metal prong that is designed to divert electrical current into the ground instead of back into a piece of equipment in case of a short circuit) was missing from the plugs for the flexible cords of electrical appliances. This affected three (First, Second, and Third floors) of three resident use floors. The findings are: 1. Observation on the First Floor on 5/3/17 at approximately 9:32 AM revealed two approximate one-half inch circular areas of an electrical junction box, in the kitchen's dishwashing room, were open, unsealed, and were not being used for electrical purposes. 2. Observation on the Third Floor on 5/3/17 at approximately 10:38 AM revealed an approximate one-half inch circular area of an electrical junction box in the housekeeping room located near Resident room [ROOM NUMBER] was open, unsealed, and was not being used for electrical purposes. 3. Observation on the Second Floor on 5/3/17 at approximately 11:47 AM revealed the plug attached to the flexible power cord for a floor drying fan, located near the receptionist's desk, was missing its ground prong. 4. Observation on the First Floor on 5/3/17 at approximately 12:24 PM revealed the plug attached to the flexible power cord for a power strip, located in the Assistant Director of Nursing's office/ In-service room, was missing its ground prong. Further observation at this time revealed the power strip was supplying power to a television and a digital video disc player located on a metal cart in the room. 5. Observation above the corridor ceiling tiles on the Third Floor on 5/4/17 at approximately 9:14 AM revealed an open, uncovered electrical junction box located near Resident room [ROOM NUMBER]. 6. Observation above the corridor ceiling tiles on the Third Floor on 5/4/17 at approximately 9:21 AM revealed an open, uncovered electrical junction box located near the soiled utility room. 7. Observation above the ceiling tiles on the Third Floor on 5/4/17 at approximately 9:24 AM revealed an open, uncovered electrical junction box located in Resident room [ROOM NUMBER]. Further observation at this time revealed an open uncovered electrical junction box located above the ceiling tiles between Resident room [ROOM NUMBER] and 205. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 6.1, 6.1.1, 1.3, 1.3.1, 1.3.2.1, 6.3.2, 6.3.2.1 2011 NFPA 70: 110.3(A)(1), 110.3 (A)(8), 314.17(A), 314.25, 314.72(C), 400.3, 400.24, 250.138(A)

Plan of Correction: ApprovedJune 5, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. The following actions were accomplished for the residents identified in the sample:
Electrical junction box in the kitchen?s dish washing room, that was opened, and unsealed was plugged by Maintenance.
Electrical junction box in the housekeeping room located near resident room [ROOM NUMBER] was repaired by Maintenance.
The plug attached to the flexible power cord for a floor drying fan near the receptionist?s desk that was missing its ground prong was repaired by Maintenance.
The plug attached to the flexible power cord for a power strip in the Assistant Director of Nursing?s office/in-service room that was missing its ground prong was replaced by Maintenance.
Uncovered electrical junction box located near Resident room [ROOM NUMBER] ? cover was replaced by Maintenance.
Uncovered electrical junction box located near the soiled utility room- cover was replaced by Maintenance.
Uncovered electrical junction box located in Resident room [ROOM NUMBER]- cover was replaced by Maintenance. Junction box located above the ceiling tiles between Resident room [ROOM NUMBER] and #205- cover was replaced Maintenance.
II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
All residents have the potential to be affected by this practice.
100% audit was conducted by the Director of Maintenance to identify any open and uncovered electrical junction boxes.
100% audit was conducted by the Director of Maintenance to ensure all electrical appliances have the necessary prongs.
III. The following system changes will be implemented to assure continuing compliance with regulations:
Director of Maintenance and Maintenance staff to be re-educated by the Administrator regarding covering or replacing any uncovered electrical junction boxes.
All disciplines will be re-educated on reporting any repairs in the Maintenance log
IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
Monthly environmental round audits for 6 months to identify any electrical junction boxes or electrical appliances in need of repair. The results of these audits will be reported to the QA Committee Monthly. Frequency of on-going audits will be determined by the QA Committee based on audit results.
Completion Date: 7/01/17
Responsibility: Director of Maintenance

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: May 9, 2017
Corrected date: July 1, 2017

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 5/9/17, flammable liquids and laundry dryer ventilation ducts were not properly maintained to minimize the possibility of a fire emergency requiring the evacuation of occupants. Issues included, cans of flammable spray paint that were improperly stored in an office and the interior of laundry dryer ventilation ducts that had excessive amounts of lint within them. This affected one (First Floor) of three resident use floors. The findings are: 1. Observation on the First Floor on 5/3/17 at approximately 12:39 PM revealed five ,12 ounce cans of gray colored spray paint were stored in the Dietary office. Further observation at this time revealed the following was written on the cans: Danger, Extremely Flammable, vapor harmful, vapor may cause a flash fire, vapors may ignite explosively, contents under pressure. Contains Xylene and [MEDICATION NAME], vapors harmful, vapors may ignite explosively. Keep away from heat, sparks, and flame. Continued observation at this time revealed the door to the room did not self-close and latch into its frame and the door was not equipped with a self-closing device. Interview with the Maintenance Supervisor at the time of the observation revealed he was not aware the cans of paint were in the Dietary office and the cans of paint should not have been stored in the office. Further interview with the Maintenance Supervisor at this time revealed he had only been working at the facility for approximately three weeks. Review of the paint's Safety Data Sheets on 5/4/17 revealed the following: Extremely flammable liquid and vapor, vapors may form [MEDICAL CONDITION] with air, vapors can travel to a source of ignition and flashback, isolate from heat, electrical equipment, sparks and open flame, store in a dry well-ventilated place, store locked up. Keep away from heat, hot surfaces, sparks, open flames and other ignition sources. No smoking. Interview with the Food Service Director on 5/4/17 at approximately 8:46 AM revealed the cans of paint had been stored in the Dietary office for a couple of days. 2. Observation on the exterior of the building on 5/3/17 at approximately 2:41 PM revealed the interior of three laundry ventilation ducts were coated with an approximate one quarter inch, to one half inch thick layer of lint. Further observation at this time revealed the lint was firmly adhered to the interior of the ducts. Interview with the Maintenance Supervisor at the time of the observation revealed he was not sure when the interior of the laundry's ventilation ducts had last been cleaned. Further interview with the Maintenance Supervisor at this time revealed he was not sure which of the facility's departments was responsible for cleaning the dryer's ventilation ducts. Continued interview with the Maintenance Supervisor at this same time revealed he had only been working at the facility for approximately three weeks. Observation on the First Floor on 5/3/17 at approximately 3:09 PM revealed the three ventilation ducts that were observed on the exterior of the building were connected to the dryers located in the Laundry's Dryer Room. 10 NYCRR 415.29(a)(2),711.2(a)(1) 2012 NFPA 101: 4.6, 4.6.1.2, 4.6.12, 4.6.12.1, 19.1.1.3, 19.1.1.3.1

Plan of Correction: ApprovedJune 5, 2017

I. The following actions were accomplished for the residents identified in the sample:
The five, 12 ounce cans of gray colored spray paint were immediately removed from the Dietary office.
Laundry ventilation ducts were immediately cleaned.

II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
All residents have the potential to be affected by this practice.
100% audit of all offices was conducted, no further paint cans were founded.
100% audit of all laundry ventilation ducts was completed.

III. The following system changes will be implemented to assure continuing compliance with regulations:

Food Service Director was re-educated by the Director of Maintenance on not having spray paint or other flammable liquids stored in the office.
Director of Maintenance developed a new log book for outside duct cleaning to be completed on a monthly basis. Maintenance department was educated on the log book.

IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
An audit of offices will be conducted by the Director of Maintenance weekly for 4 weeks then monthly for 2 months. The results of these audits will be reported to the QA Committee Monthly. Frequency of on-going audits will be determined by the QA Committee based on audit results.
Director of Maintenance to review the log book monthly with the Administrator.
Completion Date: 7/01/17
Responsibility: Director of Maintenance

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: July 6, 2017
Corrected date: August 3, 2017

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 5/9/17, the building was not completely protected by an automatic sprinkler system. Issues included closets and lockers that did not have sprinkler heads installed within them. This affected two (First and Second Floors) of three resident use floors. The findings are: 1. Observation on the First Floor on 5/3/17 at approximately 1:22 PM revealed a storage closet located in the business office did not have a sprinkler head installed within it. Further observation at this time revealed the closet had two sliding style doors that could be manually opened and closed. Further observation at this time revealed the closet was being used to store office supplies. Interview with the Maintenance Director at the time of the observation revealed he was not aware the closet did not have a sprinkler head installed within it and he had only been working at the facility for approximately three weeks. 2. Observation on the Second Floor on 5/5/17 at approximately 12:33 PM revealed an approximate six-foot tall by eight-inch wide by 18-inch deep locker that was built into the wall in Resident room [ROOM NUMBER] did not have a sprinkler head installed within it. Further observation at this time revealed the locker had a swinging style door that could be manually opened and closed. Continued observation at this time revealed the locker was being used to store clothing. 3. Observation on the Second Floor on 5/5/17 at approximately 12:38 PM revealed an approximate six-foot tall by eight-inch wide by 18-inch deep locker that was built into the wall in Resident room [ROOM NUMBER] did not have a sprinkler head installed within it. Further observation at this time revealed the locker had a swinging style door that could be manually opened and closed. Continued observation at this time revealed the locker was being used to store clothing. 4. Observation on the Second Floor on 5/5/17 at approximately 12:39 PM revealed an approximate six-foot tall by eight-inch wide by 18-inch deep locker that was built into the wall in Resident room [ROOM NUMBER] did not have a sprinkler head installed within it. Further observation at this time revealed the locker had a swinging style door that could be manually opened and closed. Continued observation at this time revealed the locker was being used to store clothing. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.5, 19.3.5.1, 9.7, 9.7.1, 9.7.1.1(1) 2010 NFPA 13: Standard for the Installation of Sprinkler Systems**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the Life Safety Code Post Survey Revisit #1, completed on 7/6/17, the building was not completely protected by an automatic sprinkler system. Issues included storage lockers that did not have sprinkler heads installed within them. This is a Continuing Deficiency from the Life Safety Code survey completed on 5/9/17 that affected two (First, Second Floors) of three resident use floors. The findings are: 1. Observation of the Second Floor on 7/6/17 at approximately 11:00 AM revealed an approximate six-foot tall by eight-inch wide by 18-inch deep locker, that was built into the wall in Resident room [ROOM NUMBER], did not have a sprinkler head installed within it. Further observation at this time revealed the locker had a swinging style door that could be manually opened and closed. 2. Observation of the Second Floor on 7/6/17 at approximately 11:05 AM revealed an approximate six-foot tall by eight-inch wide by 18-inch deep locker, that was built into the wall in Resident room [ROOM NUMBER], did not have a sprinkler head installed within it. Further observation at this time revealed the locker had a swinging style door that could be manually opened and closed Interview with the Administrator on 7/6/17 at approximately 12:05 PM revealed that based on the complexity of the deficiencies and availability of maintenance staff, more time would be needed to correct these deficiencies. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.5, 19.3.5.1, 9.7, 9.7.1, 9.7.1.1(1) 2010 NFPA 13: Standard for the Installation of Sprinkler Systems`

Plan of Correction: ApprovedJuly 24, 2017

I. The following actions were accomplished for the residents identified in the sample:
Storage office doors located in the business office were immediately removed.
Room# 107- Six foot tall by eight-inch wide by 18-inch deep locker that was built into the wall to be removed, wall to be repaired with wall board. All residents clothing from the storage locker was moved to the available closet space.
Room# 110- Six foot tall by eight-inch wide by 18-inch deep locker that was built into the wall to be removed, wall to be repaired with wall board. All residents clothing from the storage locker was moved to the available closet space.
Room# 112- Six foot tall by eight-inch wide by 18-inch deep locker that was built into the wall to be removed, wall to be repaired with wall board. All residents clothing from the storage locker was moved to the available closet space.
II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
All residents have the potential to be affected by this practice.
100% audit was conducted by the Director of Maintenance of resident rooms to ensure no other rooms had lockers in them.
III. The following system changes will be implemented to assure continuing compliance with regulations:
Storage lockers will not be used unless they have a sprinkler head in them, and approved by Director of Maintenance to ensure they meet the requirements of NFPA 13.

IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
Director of Maintenance will report to the QA Committee Monthly if any new storage locker is installed.
Completion Date: 7/01/17
Responsibility: Director of Maintenance

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: May 9, 2017
Corrected date: July 1, 2017

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 5/9/17, the building's automatic sprinkler system was not properly maintained. Issues included the automatic sprinkler system was not inspected and tested on a quarterly basis, gauges for the building's automatic sprinkler system were not tested or replaced within the last five years, spray patterns of sprinkler heads were obstructed, and items were stored directly below and less than 18 inches away from sprinkler heads. This affected three (First, Second, and Third Floors) of three resident use floors. The findings are: 1. Observation on the Third Floor on 5/3/17 at approximately 11:25 AM revealed a full length shower curtain, in the shower stall of the of the tub room located near Resident room [ROOM NUMBER], was obstructing the spray pattern of a sprinkler head located in the room. A sprinkler head was not installed within the shower stall. 2. Observation on the Second Floor on 5/3/17 at approximately 12:06 PM revealed a wall mounted cabinet was obstructing the spray pattern of a sprinkler head located in the medication storage/ medical supply room. Interview with the Maintenance Supervisor at the time of the observation revealed he was not aware of the obstruction and that he had only been working at the facility for approximately three weeks. 3. Observation on the First Floor on 5/3/17 at approximately 12:51 PM revealed a cardboard box, a plastic box, and a beach ball were stored on top of a cabinet directly below and less than 18 inches away from a sprinkler head in the Activities room. Further observation at this time revealed the cardboard box, the plastic box, and the beach ball were obstructing the spray pattern of the sprinkler head. 4. Observation on the First Floor on 5/3/17 at approximately 12:55 PM revealed two, approximately eight-foot-long by four-inch-wide pieces of hand rail, were stored across the top of pipes, obstructing the spray pattern of a sprinkler head installed in the Boiler room. 5. Observation on the First floor on 5/3/17 at approximately 2:12 PM revealed a cardboard box, full of oxygen tank covers, was stored directly below and less than 18 inches away from a sprinkler head in the Medical Records storage room. 6. Observation on 5/3/17 at approximately 3:01 PM revealed 9 - 11 was written on the face of one of the building's automatic sprinkler system gauges located in the laundry washer room. Review of Fire Sprinklers Inspection reports on 5/4/17 revealed the following item was checked No under the heading Site Inspection on reports dated 11/4/16, 8/4/17, and 5/17/16; Gauges in good condition and showing normal air/water pressure & tested /replaced within 5 years. An interview with the Maintenance Supervisor on 5/4/17 at approximately 3:00 PM revealed he had no documentation that showed the last time the building's automatic sprinkler system's gauges had been tested or replaced. He was not sure when the gauges had been tested or replaced, and he had only been working at the facility for three weeks. 7. Observation on the Third Floor on 5/3/17 at approximately 3:30 PM revealed three cardboard boxes, a three-ring binder, and an accordion style binder were stored directly below and less than 18 inches away from a sprinkler head located in the medical records storage closet located near Resident room [ROOM NUMBER]. 8. Review of Fire Sprinklers Inspection reports on 5/4/17 revealed the facility did not have documentation that the building's automatic sprinkler system had been inspected and tested during the First quarter (January, February, and March) of (YEAR). Further review of these reports, at this time, revealed the last time the building's sprinkler system was inspected and tested was on 11/4/16. Interview with the Maintenance Supervisor on 5/4/17 at approximately 2:30 PM revealed he was not sure if the building's sprinkler system had been inspected and tested in the First quarter of (YEAR) and he had only been working at the facility for approximately three weeks. Interview with the Administrator on 5/5/17 at approximately 9:25 AM revealed the building's automatic sprinkler system was not inspected and tested in the First quarter of (YEAR) because an inspection was not scheduled. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 9.7.5 2011 NFPA 25: 5.1.1, 5.1.1.2, 5.2, 5.2.1.2, 5.1.2.3, 5.3.2, 5.3.2.1,

Plan of Correction: ApprovedJune 5, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. The following actions were accomplished for the residents identified in the sample:
Wall mounted cabinet in the second floor medication storage/medical supply room was removed and wire shelving provided.
Following items in the activities room were removed from the top of the cabinet: cardboard box, plastic box, and beach ball that were identified as being directly below and less than 18 inches away from a sprinkler head.
Two pieces of handrail that were stored across the tops of pipes, obstructing the spray pattern of a sprinkler head in the boiler room were removed.
The cardboard box that was stored directly below and less than 18 inches away from a sprinkler head in the Medical Records storage room was removed.
An outside agency is scheduled to come to the facility to conduct the 5 year obstruction investigation inspection.
Three-ring binder, and an accordion style binder that were stored directly below and less than 18 inches away from a sprinkler head in medical record storage closet near resident room [ROOM NUMBER] were removed.
An outside agency is schedule to come in and inspect and test the automatic sprinkler system.
II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
All residents have the potential to be affected by this practice.
100% audit was conducted by the Director of Maintenance of offices and storage spaces to ensure there were no items directly below and less than 18 inches away from a sprinkler head.
III. The following system changes will be implemented to assure continuing compliance with regulations:
All managerial and office staff was re-educated by the Director of Maintenance regarding not storing anything directly below and less than 18 inches away from a sprinkler head in the Medical Record Storage Room, Business Office, and Activities Room.
A tape line was put on the wall in the medical records storage room to indicate nothing can be put above the line.
Log books to be audited by the Director of Maintenance to ensure that all inspections are scheduled as needed and remain in compliance.

IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
Environmental audit tool to include audits of offices and storage spaces conducted by the Director of Maintenance. Results of these audits will be presented to the QA Committee Monthly. Frequency of on-going audits will be determined by the QA Committee based on the audit results.
Director of Maintenance and Administrator to meet monthly to review Log Books.
Completion Date: 7/01/17
Responsibility: Director of Maintenance

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: July 6, 2017
Corrected date: August 3, 2017

Citation Details

Based on observation, interview, and record review during a Life Safety Code survey completed on 5/9/17, vertical openings between the building's floors were not properly protected. Issues included plumbing chases that were not enclosed with construction having a fire resistance rating of at least one hour. This affected three (First, Second, and Third Floors) of three resident use floors. 1. Observation on the First Floor, in the Director of Nursing's office on 5/3/17 at approximately 12:30 PM revealed the following: - An approximate three-foot long by 12-inch wide unsealed penetration through one of the office's walls. Further observation at this time revealed this unsealed penetration was into a plumbing chase that extended between all three floors of the building. - An approximate ten-inch long by ten-inch wide unsealed penetration through the back wall of the plumbing chase opened into a medication storage room, located in the Director of Nursing's office. - The door to the medication storage room had an approximate 20-inch long by 16-inch wide unsealed louvre through it. - The door to the Director of Nursing's office would not self-close and latch into its doorframe and it did not have a self-closing mechanism installed on it. Interview with the Maintenance Supervisor, at this same time, revealed the chase extended between all three floors of the building and he was not aware that it was open and unsealed. Further interview with the Maintenance Supervisor at this time revealed he had only been working at the facility for approximately three weeks. Interview with the Administrator on 5/3/17 at approximately 1:08 PM revealed there was a plumbing leak in the building approximately one and half months ago. The access panel into the plumbing chase in the Director of Nursing's office had been removed, and he was not sure why the panel had not been replaced. 2. Observation on the First Floor on 5/3/17 at approximately 12:47 PM revealed an approximate eight-inch long by eight-inch wide unsealed penetration through one of the walls of the Medical Director's office. Further observation at this time revealed the penetration was into a plumbing chase that extended between all three floors of the building. Continued observation at this time revealed the penetration was located behind a file cabinet and a refrigerator located in the room. Interview with the Maintenance Supervisor at the time of the observation revealed the chase extended between all three floors of the building and he was not aware that it was open and unsealed. Further interview with the Maintenance Supervisor at this time revealed he had only been working at the facility for approximately three weeks. Interview with the Administrator on 5/3/17 at approximately 1:08 PM revealed he was not aware of the open unsealed plumbing chase in the Medical Directors office. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 8.6, 8.6.1(1), 8.6.2, 8.6.4.2Based on observation and interview during the Life Safety Code Post Survey Revisit #1, completed on 7/6/17, vertical openings between the building's floors were not properly protected. Issues included plumbing chases that were not enclosed with construction having a fire resistance rating of at least one hour. This is a Continuing Deficiency from the Life Safety Code survey completed on 5/9/17 that affected three (First, Second, Third Floors) of three resident use floors. 1. Interview with the Maintenance Supervisor on 7/6/17 at approximately 10:50 AM revealed the approximate ten-inch long by ten-inch wide unsealed penetration through the back wall of the plumbing chase, that opened into a medication storage room, located in the Director of Nursing's office, had not been sealed. Observations of the door to this storage room reveled the door was locked and was not accessible for interior observation. Further observations revealed the door to the medication storage room had an approximate 20-inch long by 16-inch wide unsealed louver through it. Continued interview with the Maintenance Supervisor, at this same time, revealed the chase extended between all three floors of the building. Interview with the Administrator on 7/6/17 at approximately 12:05 PM revealed that based on the complexity of the deficiencies and availability of maintenance staff, more time would be needed to correct these deficiencies. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 8.6, 8.6.1(1), 8.6.2, 8.6.4.2

Plan of Correction: ApprovedJuly 24, 2017

I. The following actions were accomplished for the residents identified in the sample:
The following penetrations have been sealed: three-foot long by 12 inch wide penetration in one of the walls in the Director of Nursing?s Office. Ten-inch long by ten inch wide penetration through the back wall of the plumbing chase that opened into a medication storage room in the Director of Nursing?s Office. The eight-inch wide penetration through one of the walls in the Medical Director?s office.
II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
All residents have the potential to be affected by this practice.
100% audit was conducted of the Director of Nursing?s office and Medical Director?s no other issues were identified.
III. The following system changes will be implemented to assure continuing compliance with regulations:
Director of Maintenance and maintenance staff to be educated by the Administrator on the need to ensure all penetrations are sealed.
All contracture work done in facility will be inspected following the work by the Maintenance Director to ensure no penetrations present.
IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
Random monthly audits by the Director of Maintenance for 6 months looking for unsealed penetrations. The results of these audits will be reported to the QA Committee Monthly. Frequency of on-going audits will be determined by the QA Committee based on audit results.
Completion Date: 7/01/17
Responsibility: Director of Maintenance