Sapphire Center for Rehabilitation and Nursing of Central Queens, LLC
December 19, 2016 Certification Survey

Standard Health Citations

FF10 483.10(f)(10)(v):CONVEYANCE OF PERSONAL FUNDS UPON DEATH

REGULATION: (v) Conveyance upon discharge, eviction, or death. Upon the discharge, eviction, or death of a resident with a personal fund deposited with the facility, the facility must convey within 30 days the resident?s funds, and a final accounting of those funds, to the resident, or in the case of death, the individual or probate jurisdiction administering the resident?s estate, in accordance with State law.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2016
Corrected date: January 3, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility did not ensure that the personal funds were conveyed within 30 days of the resident's death. This is evident for 3 of 3 residents reviewed for Personal Funds. The findings are: 1) Resident #165 expired in the facility on [DATE]. The resident personal fund account documented a balance of $270.32. 2) Resident #29 expired in the facility on [DATE]. The resident personal fund account documented a balance of $1,290.42. 3) Resident #291 expired in the facility on [DATE]. The resident personal fund account documented a balance of $350.07. There was no documented evidence that the funds were conveyed within 30 days of the residents expiration to the appropriate jurisdiction. An interview was conducted with the Bookkeeper on [DATE] at approximately 2:00 PM. The bookkeeper stated that upon death a letter is mailed to the family requesting them to obtain/provide a Letter of Administration from Surrogates Court. If the letter is not provided within thirty days she then mails the balance to the public administrator. The Bookkeeper also stated that she was waiting for a response from the family but will send the funds today. She further stated that every two months she reviews and cleans up the inactive list. The policy and procedure titled Resident's Personal Funds Management Policy dated [DATE] documents that in accordance with New York State Department of Social Service regulations, (name of facility) is obligated to return all monies held for medicaid residents to the Public Administrator's Office within thirty (30) days of the expiration of the resident. Funds cannot be held longer than 30 days unless the financial sponsor advises the facility of his/her intent to obtain the proper documents from the Public Administrator's office within the prescribed timetable. 415.26 (h)(5)(iv)

Plan of Correction: ApprovedJanuary 3, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #165 Residents' funds were released by bookkeeper to her family.
[DATE]
Resident #29 Residents' funds were released by bookkeeper to the Social Security Administration.
[DATE]
Resident #291 Residents'funds were released by bookkeeper to his familiy.
[DATE]
Bookkeeper reviewed the current balances of all discharged , evicted or expired residents, and Pna funds were released to family, guardian or legal representative as needed, all in compliance .
[DATE]
Bookkeeper will monitor all the Pna account balances of all discharged , evicted, or expired residents by reviewing the Admisiions daily Census Reports.
Director of Social Services will verify that all contact information of families/relatives or guardian is accurate.
Bookkeeper will be responsible to ensure that all PNA Funds of discharged , evicted or expired residents will be released within thirty(30)days of discharge.
Bookkeeper will review the PNA inactive balances on a weekly basis.
Bookkeeper will review Resident Funds bank statement balance each month to ensure that all checks have cleared.
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Bookkeeper will conduct quarterly audits of conveyance of all resident Pna Funds and report findings to Quality Assurance Committee . Conveyance of Residents with PNA funds who have been discharged ,evicted or expired will be incoporated into Facility wide Quality Assurance Program.
Director of Social Services will be responsible for conducting quarterly contact information audits of all residents and reporting findings to Quality Assurance Committee.
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Standard Life Safety Code Citations

K307 NFPA 101:AISLE, CORRIDOR, OR RAMP WIDTH

REGULATION: Aisle, Corridor or Ramp Width 2012 EXISTING The width of aisles or corridors (clear or unobstructed) serving as exit access shall be at least 4 feet and maintained to provide the convenient removal of nonambulatory patients on stretchers, except as modified by 19.2.3.4, exceptions 1-5. 19.2.3.4, 19.2.3.5

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2016
Corrected date: February 17, 2017

Citation Details

19.2.3.4* Any required aisle, corridor, or ramp shall be not less than 48 in. (1220 mm) in clear width where serving as means of egress from patient sleeping rooms, unless otherwise permitted by one of the following: (1) Aisles, corridors, and ramps in adjunct areas not intended for the housing, treatment, or use of inpatients shall be not less than 44 in. (1120 mm) in clear and unobstructed width. (4) Projections into the required width shall be permitted for wheeled equipment, provided that all of the following conditions are met: (a) The wheeled equipment does not reduce the clear unobstructed corridor width to less than 60 in. (1525 mm). (b) The health care occupancy fire safety plan and training program address the relocation of the wheeled equipment during a fire or similar emergency. (c)*The wheeled equipment is limited to the following: i. Equipment in use and carts in use ii. Medical emergency equipment not in use iii. Patient lift and transport equipment Based on observation and staff interview, it was determined that the facility did not ensure that corridors in nursing units were maintained unobstructed in accordance with 2012 NFPA 101 section 19.2.3.4 as evidenced by the facility ' s 1st floor nursing unit corridor serving as means of egress that was obstructed by wheeled equipment (linen carts) reducing the clear unobstructed corridor width to 36 in. This was noted on 1 out of 7 floors of the facility. The findings are: On 12/14/2016 and 12/15/2016 during the life safety recertification survey between 9am and 3pm, it was observed that the facility ' s 1st floor nursing unit corridor was approximately 62 in. wide and was used to store wheeled equipment such as linen carts that reduced the clear unobstructed corridor width to 36 in. In an interview on 12/15/16 at approximately 11:00 am with the Director of Nursing (DN) of the facility, she stated that linen carts were placed in the corridor for infection control issues since they could not be stored in the 1st floor nursing unit bathrooms. The DN also stated that the unit was not provided with a clean linen storage room. In an interview on 12/15/16 at approximately 11:30 am with the Administrator of the facility (AF), he stated that he had the impression that 2012 NFPA 101 allowed wheeled equipment such as linen carts in the corridor. 2012 NFPA 101 19.2.3.4, exceptions 1-5 711.2(a)(1)

Plan of Correction: ApprovedMarch 7, 2017

All linen carts and resident wheel chairs were removed from the First Floor Corridor in the presence of surveyors.
12/14/2016-12/15/2016
All other Resident Floors (2nd-6th) were surveyed by Director of Nursing and Director of Maintenance , all in compliance.
12/15/2016
Storage Closet on First Floor across from Nurse Station was converted to clean line closet and labeled as such eliminating the use of move able clean linen carts.
12/16/2016
Policy and Procedure revised to address maintaining the hallway unobstructed, to ensure that wheelchairs are stored in the hallway, to be stored in residents room ,or in main activities dining room when not in use, during the day residents will be moved to the main dining room for meals, activities or visitation with families.
12/16/2016
Staff development coordinator in-services all staff on the new policy.
12/16/2016
Rn Supervisors, Charge Nurses and Assistant Director Nursing will be responsible for ensuring compliance during daily environmental rounds.
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Director or Nursing will be responsible for conducting quarterly audits to monitor compliance and report findings the Quality Assurance Committee.
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K307 NFPA 101:GAS EQUIPMENT - CYLINDER AND CONTAINER STORAG

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2016
Corrected date: February 17, 2017

Citation Details

2012 NFPA 99: 11.3.4 Signs 11.3.4.1 A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure. 11.3.4.2 The sign shall include the following wording as a minimum: CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING Based on observation and staff interview, the facility failed to ensure that oxygen storage rooms were provided with the appropriate sign with the correct wording. This occurred on 2 of 7 floors of the facility. The findings are: On 12/14/2016 between the hours of 9am and 3pm during the recertification survey, the following was observed: Oxygen storage rooms were noted to be located on the 6th and 5th floors of the facility. These storage rooms lacked the required signs containing, at a minimum, the words Caution: Oxidizing gas(es) stored within no smoking . In an interview on 12/14/2016 at approximately 10:30 am with the Director of Maintenance, he stated he could replace the signs on the oxygen rooms. 2012 NFPA 99:5 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedMarch 7, 2017

Maintenance Director installed signs that are readable from a distance of five (5) feet on all oxygen storage rooms on the 5th and 6th Floor resident floors.
Floors with the following wording:
Caution
Oxidizing Gas (ES) Stored within
No Smoking
12/23/2016
Maintenance Director surveyed the facility and installed readable signs on all floors/ locations with oxygen storage cabinets, all in compliance.
12/23/2016
Maintenance Director will be responsible for ensuring that all signs remain in place, and if additional expansion or constructed is conducted in the facility that the areas are evaluated for the need of additional signs, and will be into facility wide Preventative Maintenance Program.
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Maintenance Director will conduct quarterly audits of the Gas Cylinder Storage Management Program and report findings to Quarterly Assurance Committee.
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K307 NFPA 101:MEANS OF EGRESS - GENERAL

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2016
Corrected date: February 17, 2017

Citation Details

7.2 Means of Egress Components. 7.2.1 Door Openings. 7.2.1.1 General. 7.2.1.1.1 A door assembly in a means of egress shall conform to the general requirements of Section 7.1 and to the special requirements of 7.2.1. 7.2.1.1.2 Every door opening and every principal entrance that is required to serve as an exit shall be designed and constructed so that the path of egress travel is obvious and direct. Windows that, because of their physical configuration or design and the materials used in their construction, have the potential to be mistaken for door openings shall be made inaccessible to the occupants by barriers or railings. 19.2 Means of Egress Requirements. 19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11. 19.2.2.2.1 Doors complying with 7.2.1 shall be permitted. 19.2.10.1 Means of egress shall have signs in accordance with Section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4. Based on observation and staff interview, the facility failed to ensure that exit paths were maintained and provided a clear and unobstructed path. Specifically, exits doors opened 90 degrees into the exit discharge path. This occurred on 2 of 6 exit doors on the 1st floor of the facility. The findings are: On 12/14/2016 and 12/15/2016 between the hours of 9am and 3pm during the recertification survey, the following was observed: On the 1st floor nursing unit, 2 emergency exit doors leading to the outside of the facility were observed. One door was labeled North and the other, South . Upon inspection of the South exit door, it was revealed that when in the open position, the door swung 90 degrees into the exit discharge path of egress. When measured with the door in the open position, the clearance between the door and the railing was 9.5 inches. Upon inspection of the North exit door, the same situation occurred with the door swinging 90 degrees into the exit discharge path. When in the open position, the clearance between the door and the railing measured 23 inches. In an interview on 12/14/2016 at approximately 3pm with the Director of Maintenance, he stated he could make adjustments to the north exit door. In an interview on 12/15/2016 at approximately 11:30am with the Administrator, he stated he will evaluate the options that they have to address the issue and that they might apply for a waiver. 2012 NFPA101:7, 19 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedMarch 7, 2017

North Exit Door, First Floor hinges were re-positioned and reversed by contractor, handrail was cut back to ensure that metal door swings back 180 degrees to the side wall ensuring 100% egrees clearance.
02/16/17
South Exit Door, First Floor door frame was built out: new hinges were installed to ensure that door swings back 180 degrees to ensure 100% egrees clearance.
02/16/17
Maintenance Director surveyed all facility egrees doors of the 01/07/17 of the entire building all in compliance.
01/07/17-01/08/17
Maintenance Director will be responsible for monitoring equipment compliance on a daily basis during environmental rounds, Maintenance Director will be responsible for making any necessary repairs, or coordination of repairs with outside contractor to ensure compliance, means of egrees components monitoring will be incorporated into Facility Wide Preventative Maintenance Program.
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Maintenance Director will be responsible for maintaining compliance by conducting quarterly audits and reporting findings to Quality Assurance Committee.
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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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2016
Corrected date: February 17, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA101: 19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. 2010NFPA13: 8.15.5 Elevator Hoistways and Machine Rooms. 8.15.5.1* Sidewall spray sprinklers shall be installed at the bottom of each elevator hoistway not more than 2 ft (0.61 m) above the floor of the pit. 8.15.5.2 The sprinkler required at the bottom of the elevator hoistway by 8.15.5.1 shall not be required for enclosed, noncombustible elevator shafts that do not contain combustible hydraulic fluids. 8.15.5.3* Automatic sprinklers in elevator machine rooms or at the tops of hoistways shall be of ordinary- or intermediate temperature rating. 8.15.5.4* Upright, pendent, or sidewall spray sprinklers shall be installed at the top of elevator hoistways. 8.15.5.5 The sprinkler required at the top of the elevator hoistway by 8.15.5.4 shall not be required where the hoistway for passenger elevators is noncombustible or limited-combustible and the car enclosure materials meet the requirements of ASME A17.1, Safety Code for Elevators and Escalators. 8.15.5.6 Sprinklers shall be installed at the top and bottom of elevator hoistways where elevators utilize [MEDICATION NAME]-coated steel belts or other similar combustible belt material. 8.5.5.3* Obstructions That Prevent Sprinkler Discharge from Reaching the Hazard. 8.5.5.3.1 Sprinklers shall be installed under fixed obstructions over 4 ft (1.2 m) wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors. Based on observation and staff interview, the facility failed to ensure that elevator hoistways and areas under fixed obstructions over 4ft wide in the facility were sprinklered. This occurred in 1 of 3 elevator hoistways within the facility and under the greater than 4 ft. fixed obstructions in the walk-in refrigerator area within the facility ' s kitchen and the housekeeping director office, both observed in the facility ' s basement. The findings are: On 12/14/2016 and 12/15/2016 between the hours of 9am and 3pm during the recertification survey, the following was observed: (1) In the basement of the facility, a freight elevator was observed. This elevator connected the basement floor to the first floor and is hydraulically operated. Upon inspection, it was revealed that the elevator shaft did not contain a sprinkler at the top or the bottom of the shaft. (2) The desk area with combustible items under the greater than 4 ft. wide low ceiling located in the basement ' s housekeeping director office lacked sprinklers. (3) The area under the greater than 4 ft. ductwork located at the vestibule within the walk-in refrigerator area in the facility ' s kitchen lacked sprinklers. Also, it was noted that combustible items (trays and utensils) were stored under the ductwork. In an interview on 12/14/2016 at approximately 12:30 pm with the Director of Maintenance, he stated he does not think the elevator contains a sprinkler. In an interview on 12/15/16 at approximately 3:25 pm with the Administrator of the facility (AF), he stated that the sprinkler vendor will evaluate if the sprinklers installed in the Director of Housekeeping office and kitchen ' s walk-in refrigerator area required additional sprinklers. 2012 NFPA101:19 2010NFPA13: 8 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedMarch 7, 2017

Sprinkler Head was installed in Freight Elevator Shaft by licensed Sprinkler Contractor.
01/17/2017
Sprinkler Head was installed in Housekeepers Director Basement Office by licensed Sprinkler Contractor.
01/16/2017
Sprinkler Head was installed in Kitchen Vestibule walkway to Walk in Freezer in basement by licensed Sprinkler Contractor.
01/17/2017
Maintenance Director surveyed the entire facility and all areas were in compliance.
1/15-1/16/2017
Maintenance Director will be responsible for ensuring that all NFPA 25 inspections , testing, inspections and Maintenance of Sprinkler Components is conducted and remain in compliance and will incorporated into Facility wide Preventative Maintenance Program
Maintenance Director will be responsible to ensure that all building expansion are evaluated for the need if additional Sprinkler Coverage.
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Maintenance Director will be responsible for conducting quarterly audits of Sprinkler system and all its components and report findings to Quality Assurance Committee.
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ZT1N 713-1:STANDARDS OF CONSTRUCTION FOR NEW EXISTING NH

REGULATION: N/A

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2016
Corrected date: February 17, 2017

Citation Details

713.-1.3 Nursing Units Each nursing unit shall include the following service area and shall meet the following minimum requirements: (c) A minimum of one clean utility room and one soiled utility room on each resident floor. Based on observation and staff interview, the facility failed to ensure that nursing units were provided with a minimum of one clean utility room and one soiled utility room on each resident floor. This was observed on 1 of 6 nursing units within the facility. The findings are: On 12/14/2016 and 12/15/2016 between the hours of 9am and 3pm during the recertification survey, it was observed that the facility's 1st floor nursing unit lacked, at a minimum, one clean utility room. In an interview on 12/15/16 at approximately 11:00 am with the Director of Nursing (DN) of the facility, she stated that linen carts were placed in the corridor for infection control issues since they couldn ' t be stored on the 1st floor nursing unit bathrooms. The DN also stated that the unit was not provided with a clean linen storage room. In an interview on 12/15/2016 at approximately 3:15pm, the Administrator stated the facility has never had clean or soiled storage areas for that nursing unit. He further stated he would try to come up with a solution for storage. 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedMarch 7, 2017

First Floor Nursing Unit storage closet was converted to Clean Storage Room
12/22/2016
Residents? Floors 2, 3, 4 and 5 have Soiled Utility Rooms with negative pressure exhaust and sink.
Resident Floors 2nd, 3rd, 4th and 5th have Clean Linen Alcoves; unused tub rooms were converted to Clean Utility Room with a sink and a positive pressure air supply.
1/30/17
Residents? Floor # 6 Soiled Utility Room is adjacent to elevator; has sink and negative pressure exhaust system.
Resident Floor # 6 Clean Linen Room is located adjacent to Day Room; unused tub room was converted to Clean Utility Room with sink and positive pressure air supply.
01/31/2017
Director of Maintenance surveyed entire building; the entire facility is in compliance
02/01/17
Staff Development Coordinator In-serviced Nursing and Housekeeping Staff, on location and usage of Clean Linen Rooms and Soiled Utility Rooms.
02/02/17-02/03/17-02/07/17
Director of Maintenance will be responsible for maintaining equipment and making any necessary repairs to ensure compliance. Maintaining of All storage and utility areas will be incorporated into the facility-wide Preventative Maintenance Program
/On-Going
Director of Maintenance will be responsible for monitoring and maintaining compliance by conducting periodic audits and reporting findings to the Quarterly Quality Assurance Committee
/On-Going