Fox Run at Orchard Park
September 28, 2018 Certification Survey

Standard Health Citations

ZT1N 415.19:INFECTION CONTROL

REGULATION: N/A

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 28, 2018
Corrected date: October 26, 2018

Citation Details

Based on interview and record review during the Standard Survey completed on 9/28/18, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility had not performed an environmental assessment of the facility for Legionella and intervals for the sampling and analysis of the building's water system for Legionella had exceeded 90 days. This affected one (Second Floor of the Health Center) of one resident unit. The finding is: During an interview on 9/26/18 at 1:02 PM, the Director of Facilities stated the facility had not conducted an environmental assessment of the building for Legionella. The facility had been in contact with three outside contractors during (YEAR) and each contractor informed the facility that the facility did not have to conduct a Legionella risk assessment because the facility did not have cooling towers. In mid-December of (YEAR) the facility became aware of the Legionella requirements and hired an outside contractor to conduct sampling and analysis of the building's potable water system on 2/1/18. No other sampling and analysis had been conducted for the building's potable water system. Review of documentation provided by the facility on 9/26/18 revealed an outside contractor had collected ten water samples from the building's potable water system on 2/1/18, the samples had been analyzed, and no Legionella had been detected. On 9/26/18, a review of the facility's Legionella policy, dated 1/2018, revealed the facility would adopt and implement a Legionella culture sampling and management plan for the building's potable water system in accordance with the New York State Code of rules and Regulations Subpart 4-2. Per the New York State Department of Health, Center for Environmental Health Regulation for the Protection Against Legionella dated 8/12/16, Part 4 of the New York State Sanitary Code Protection Against Legionella, became effective on (MONTH) 6, (YEAR). Subpart 4-2 of the regulations require all general hospitals and residential health care facilities to: - Perform and update an environmental assessment, using forms provided by the Department, by (MONTH) 1, (YEAR). - Adopt and implement a Legionella sampling and management plan by (MONTH) 1, (YEAR) for the facility's potable water system that includes routine Legionella culture sampling and analysis and immediate Legionella sampling under specific conditions. The plan shall include a schedule to conduct: Routine Legionella culture sampling and analysis at intervals not to exceed 90 days in the first year and annually thereafter. 415.19(a)(1) 10 NYCRR Subpart 4-2.3(a), 4-2.4(2)

Plan of Correction: ApprovedOctober 22, 2018

I210
Infection Control
1. The facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility did not conduct an environmental assessment for Legionella, and the intervals for the sampling and analysis of the building's water system for Legionella had exceeded 90 days.
2. The Director of Facilities completed DOH-5222 Environmental Assessment of Water Systems in Healthcare Settings. The Director of Facilities also contacted an outside contractor to implement a Legionella sampling and management plan which is scheduled to begin in October, (YEAR).
3. Legionella culture sampling and analysis is scheduled to begin on 10/26/2018 and will continue quarterly for one (1) year and annually thereafter if no Legionella or other pathogens are found in the building's water system.
4. The contractor reports will be brought to the QAA committee in December, (YEAR) and on a quarterly basis for review by the Director of Facilities/designee.
5. Overall responsibility to ensure action is implemented and maintained is with the Director of Facilities/designee. Completion date is 10/26/2018.

FF11 483.80(a)(1)(2)(4)(e)(f):INFECTION PREVENTION & CONTROL

REGULATION: §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 28, 2018
Corrected date: October 26, 2018

Citation Details

Based on interview and record review during a Standard Survey completed on 9/28/18, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility did not conduct a Legionella risk assessment of the building to identify where Legionella and other opportunistic pathogens could grow and spread in the building's water system. This affected one (Second Floor of the Health Center) of one resident unit. The finding is: On 9/26/18, a review of the facility's Legionella policy, dated of 1/2018, revealed the policy did not contain documentation that a Legionella risk assessment had been conducted for the building. During an interview on 9/27/18 at 12:42 PM the Administrator and the Director of Facilities stated, the facility had not conducted a Legionella risk assessment for the building. The facility had been in contact with three outside contractors during (YEAR) and each contractor informed the facility that the facility did not have to conduct a Legionella risk assessment because the facility did not have cooling towers. In mid-December of (YEAR) the facility became aware of the Legionella requirements and hired an outside contractor to collect water samples from the facility water supply on 2/1/18. Per Centers for Medicare & Medicaid Services Survey and Certification Letter S&C 17-30 subject: Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD) dated 6/2/17 and revised 6/9/17: Healthcare Facilities must conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system. 415.19(a)(1)

Plan of Correction: ApprovedOctober 22, 2018

F880
Infection Prevention & Control
1. The facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility did not conduct a Legionella risk assessment of the building to identify when Legionella and other pathogens could grow and spread in the building's water system in (YEAR), nor conduct a quarterly risk assessment for the year thereafter.
2. The Director of Facilities immediately contacted an outside contractor to develop a risk assessment plan and remediation plan if Legionella or other pathogens were found in the building's water system.
3. Quarterly water sampling is scheduled to begin on 10/26/2018 and will continue quarterly for one (1) year and annually thereafter if no Legionella or other pathogens are found in the building's water system.
4. The contractor reports will be brought to the QAA committee in December, (YEAR) and on a quarterly basis for review by the Director of Facilities/designee.
5. Overall responsibility to ensure action is implemented and maintained is with the Director of Facilities/designee. Completion date is 10/26/2018.

Standard Life Safety Code Citations

K307 NFPA 101:CORRIDORS - CONSTRUCTION OF WALLS

REGULATION: Corridors - Construction of Walls 2012 EXISTING Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames. If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area. 19.3.6.2, 19.3.6.2.7

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 28, 2018
Corrected date: September 29, 2018

Citation Details

Based on observation, interview, and record review during a Life Safety Code survey completed on 9/28/18, the building's corridor walls were not properly maintained. Issues included a corridor walls were not designed to resist the passage of smoke due to unsealed penetrations and ceiling tiles being removed from lay-in-style ceiling assemblies. This affected one (Second Floor of the Health Center) of one resident unit. The findings are: 1) a) Observation on the Second Floor, on 9/25/18 at 11:16 AM, revealed a two-inch long by two-inch wide penetration through the corridor wall that separated the mechanical room by Resident Room #436 from the Second Floor corridor. Further observation at this time revealed the room's lay-in style ceiling assembly had been removed and the penetration was located above the mechanical room's corridor door. Continued observation at this time revealed no staff or contractors were working in the room. During the observation, the Director of Facilities stated an outside contractor had been working in the room as part of the building's construction project and the last time the contractor had been working in the room was 9/24/18. b) Observation on the Second Floor, on 9/25/18 at 11:40 AM, revealed six, two-foot long by two-foot wide ceiling tiles had been removed from the ceiling assembly in the storage room by Resident Room #443. Further observation at this time revealed at least four, two-inch long by two-inch wide penetrations through the corridor wall that separated the room from the Second Floor corridor. Continued observation at this time revealed two, two-foot long by two-foot wide ceiling tiles had been removed from the ceiling assembly in the corridor outside of the storage room. The missing ceiling tiles in the storage room and the Second Floor corridor and the penetrations through the corridor wall between the storage room and the Second Floor corridor would allow smoke and fire to pass between the room and corridor. During the observation, the Director of Facilities stated an outside contractor had been working in the room as part of the building's construction project and the last time the contractor had been working in the room was 9/24/18. During an interview on 9/27/18 at 9:37 AM the Director of Facilities stated, daily rounds of the building were conducted and documented by members of the maintenance staff on the Second Shift (3:00 PM to 11:00 PM). The Director of Facilities further stated, the rounds were conducted to ensure there were no issues with the building. Review of Second Shift daily rounds sheets dated 9/22/18, 9/23/18, 9/24/18, 9/25/18, and 9/26/18 revealed they contained no documentation about ceiling tiles that had been removed from the Second Floor ceiling assemblies or the penetrations in the Second Floor corridor walls. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.6.2, 19.3.6.2.1, 19.3.6.2.3

Plan of Correction: ApprovedOctober 22, 2018

K362
Corridors - Construction of Walls
1. The facility will ensure that the buildings corridor walls are properly maintained, including proper ceiling tiles near the corridor wall and penetrations being sealed to resist the passage of smoke.
2. The Maintenance Department immediately sealed the penetration through the corridor wall that separates the mechanical room by Room #436, and the storage room near Room #443 and the corridor outside of that storage room. The ceiling assembly/ceiling tile in both of these location was also replaced.
3. A 100% audit of corridor walls and ceiling tiles in the Skilled Nursing Facility was completed on 9/26/2018 to ensure there were no other issues.
4. The Director of Facilities immediately instructed all Maintenance staff to check for unsealed penetrations and missing ceiling tiles during their daily rounds. This item was also added to our Maintenance Departments Daily Rounds Checklist immediately. The checklist is audited on a weekly basis by the Director of Facilities/designee. Audits will be brought to the QAA committee in December, (YEAR) and on a quarterly basis for review and need for continuance.
5. Overall responsibility to ensure action is implemented and maintained is with the Director of Facilities/designee. Completion date is 9/29/2018.

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: September 28, 2018
Corrected date: September 29, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during a Life Safety Code survey completed on 9/28/18, extension cords and power strips were not properly maintained. Issues included, in-use extension cords and unapproved power strips that were being used to supply power to electrical devices. This affected one (Second Floor of the Health Center) of one resident unit. The findings are: 1) a) Observation on the Second Floor, on 9/25/18 at 10:29 AM, revealed an extension cord was being used to supply power to a radio and a lamp located on a table in the corridor outside of the Main dining room across from the nurse's station. During the observation, the Director of Facilities and the Facilities Supervisor stated they were not aware the extension cord was being used to supply power to the radio and the lamp. b) Observation on the Second Floor, on 9/25/18 at 10:38 AM, revealed an extension cord was being used to supply power to two mechanical lift batteries and their charging stations located in the soiled utility room near Resident room [ROOM NUMBER]. During the observation the Director of Facilities stated, the staff knew they were not to use extension cords. 2) a) Observation on the Second Floor, on 9/26/18 at 12:21 PM revealed a power strip was being used to supply power to two sets of head phones and two speakers in Resident room [ROOM NUMBER]. Further observation at this time revealed the power strip was not approved to be used in a resident room. During the observation the Director of Facilities stated, the power strip had not been provided by the facility. b) Observation on the Second Floor, on 9/26/18 at 12:43 PM, revealed a power strip was being used to supply power to a string of decorative lights that were strung on an artificial tree in Resident room [ROOM NUMBER]. Further observation at this time revealed the power strip was not approved to be used in a resident room. During the observation the Director of Facilities stated, the power strip had not been provided by the facility. During an interview on 9/27/18 at 9:37 AM, the Director of Facilities stated daily rounds of the building were conducted and documented by members of the maintenance staff on the Second Shift (3:00 PM to 11:00 PM). The Director of Facilities further stated, the rounds were conducted to ensure there were no issues with the building. Review of Second Shift daily rounds sheets dated 9/22/18, 9/23/18, 9/24/18, 9/25/18, and 9/26/18 revealed they contained no documentation about the in-use extension cords and unapproved power strips. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 2.1, 2.2, 10.2.3.6, 10.2.4, 10.2.4.2, 10.2.4.2.1,10.2.4.2.3, 10.2.3, 10.2.3.3.3 2011 NFPA 70: 110.3(A)(1), 110.3(A)(7), 110.3(A)(8), 400.3, 400.8(1), 590.3(B)

Plan of Correction: ApprovedOctober 22, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K920
Electrical Equipment - Power cords and extensions
1. The facility will ensure that all power strips meet standards under NFPA 99 and are used with general precautions. Extension cords will not be used as a substitute for fixed wiring of a structure, and if used temporarily, are removed immediately upon completion of the purpose for which it was installed.
2. The Maintenance Department immediately replaced all non-compliant power strips and removed all extension cords. The extension cord in the corridor outside of the main dining room was replaced with a UL1363 rated power strip. The extension cord from the soiled utility room near room [ROOM NUMBER] was removed. The non-compliant power strip in room [ROOM NUMBER] was replaced with an approved UL1363 power strip. The non-compliant power strip in room [ROOM NUMBER] was replaced with an approved UL1363 power strip.
3. A 100% audit of the Skilled Nursing Facility was completed on 9/28/2018 to ensure there were no extension cords or non-compliant power strips.
4. The Director of Facilities instructed all Maintenance staff to check for extension cords and non-compliant power strips during their bi-weekly safety audits of all Skilled Nursing facility rooms and areas. The Safety Audit form completed by the Maintenance Department is audited on a monthly basis by the Director of Facilities/designee. Audits will be brought to the QAA committee in December, (YEAR) and on a quarterly basis for review.
5. Overall responsibility to ensure action is implemented and maintained is with the Director of Facilities/designee. Completion date is 9/29/2018.

K307 NFPA 101:FIRE ALARM SYSTEM - TESTING AND MAINTENANCE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 28, 2018
Corrected date: September 29, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during a Life Safety Code survey completed on 9/28/18, smoke detectors were not properly maintained. Issues included, smoke detectors were covered with tape and vinyl gloves. This affected one (Second Floor of the Health Center) of one resident unit. The findings are: 1) a) Observation on the Second Floor, on 9/25/18 at 11:16 AM, revealed a smoke detector located in the mechanical room near Resident room [ROOM NUMBER] was covered with pieces of red tape and a vinyl glove. Further observation at this time revealed the room's lay-in style ceiling assembly had been removed. Continued observation at this time revealed no staff or contractors were working in the room. During this observation, the Director of Facilities stated an outside contractor had been working in the room as part of the building's construction project and the last time the contractor had been working in the room was on 9/24/18. b) Observation on the Second Floor, on 9/25/18 at 11:27 AM, revealed a smoke detector located in the corridor near Resident room [ROOM NUMBER] was covered with pieces of red tape and a vinyl glove. Further observation at this time revealed no staff or contractors were working in the area. During the observation, the Director of Facilities stated an outside contractor had been working in the corridor as part of the building's construction project and the last time the contractor had been working in this area was on 9/24/18. c) Observation on the Second Floor, on 9/25/18 at 11:33 AM, revealed a smoke detector located in the dining room for the servery by Resident room [ROOM NUMBER] was covered with pieces of red tape and a vinyl glove. Further observation at this time revealed no staff or contractors were working in the dining room. During the observation the Director of Facilities stated, an outside contractor had been working in the dining room as part of the building's construction project and the last time the contractor had been working in this room was on 9/24/18. d) Observation on the Second Floor, on 9/25/18 at 11:40 AM, revealed a smoke detector located in the storage room by Resident room [ROOM NUMBER] was covered with pieces of blue tape. Further observation at this time revealed no staff or contractors were working in the room. During an interview on 9/27/18 at 9:37 AM, the Director of Facilities stated daily rounds of the building were conducted and findings were documented by members of the maintenance staff on the Second Shift (3:00 PM to 11:00 PM). The Director of Facilities further stated, the rounds were conducted to ensure there were no issues with the building. Further interview reveled the temporary construction wall located in the corridor, near the servery by Resident room [ROOM NUMBER], had been removed on 9/22/18. Review of Second Shift daily rounds sheets dated 9/22/18, 9/23/18, 9/24/18, 9/25/18, and 9/26/18 revealed they contained no documentation about the building's smoke detectors. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 9.6.1.3, 4.5.8, 4.6.12.2 2010 NFPA 72: 14.3.1, 14.3.4, 14.5.1

Plan of Correction: ApprovedOctober 22, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K345
Fire Alarm System testing and maintenance
1. The facility will maintain all smoke detectors according to NFPA 101, 70, 72 standard for the fire alarm system - testing and maintenance.
2. The Director of Facilities immediately instructed the Maintenance Department to remove the vinyl gloves and tape from the smoke detectors. All smokes detectors, including one located in the mechanical room near room [ROOM NUMBER], the smoke detector located in the corridor near room [ROOM NUMBER], the smoke detector located in the dining room for the servery by room [ROOM NUMBER], and the smoke detector located in the storage room by room [ROOM NUMBER], were functional and in compliance after this action.
3. A 100% audit by the Director of Facilities and Maintenance Department was completed on 9/25/2018 to ensure that no other smoke detectors were covered. This item was also added to our Maintenance Departments Daily Rounds Checklist immediately. The checklist is audited on a weekly basis by the Director of Facilities/designee. Audits will be brought to the QAA committee in December, (YEAR) and on a quarterly basis to be reviewed for continuance.
5. Overall responsibility to ensure action is implemented and maintained is with the Director of Facilities/designee. Completion date is 9/29/2018

K307 NFPA 101:FUNDAMENTALS - BUILDING SYSTEM CATEGORIES

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 28, 2018
Corrected date: October 18, 2018

Citation Details

Based on interview and record review during a Life Safety Code survey completed on 9/28/18, a risk assessment was not conducted on the building's systems. Issues included, the facility did not conduct a defined and documented risk assessment for the building system categories in accordance with National Fire Protection Association (NFPA) 99 - Health Care Facilities Code. This affected one (Second Floor of the Health Center) of one resident unit. The finding is: Review of the facility's Disaster and Evacuation Policy and Procedures manual, with a reviewed date of (MONTH) (YEAR), as well as other Life Safety Code documentation provided by the facility from 9/26/18 through 9/28/18 revealed there was no documentation that confirmed a risk assessment for the building system's categories was conducted in accordance with the 2012 edition of NFPA 99, Health Care Facilities Code. During an interview on 9/26/18 at 2:23 PM, the Director of Facilities stated a risk assessment had not been conducted on the building system's categories in accordance with NFPA 99. Per the 2012 edition of NFPA 99: building systems in health care facilities shall be designed to meet system Category 1 through Category 4 requirements as detailed in this code and the categories shall be determined by following and documenting a defined risk assessment procedure. 10NYCRR 415.29(a)(2),711.2(a)(1) 2012 NFPA 99: 4.1, 4.2, 4.3

Plan of Correction: ApprovedOctober 18, 2018

K901
Fundamentals - Building System Categories
1. The facility will maintain a current risk assessment on the buildings systems in accordance with the 2012 edition of NFPA 99, Health Care Facilities Code.
2. The Director of Facilities completed a defined and documented risk assessment on building systems which will be reviewed at QAA in December, (YEAR) and annually thereafter.
3. The risk assessment will be reviewed annually to ensure accuracy.
4. Overall responsibility to ensure action is implemented and maintained is with the Director of Facilities/designee. Completion date is 10/18/2018.

PLAN BASED ON ALL HAZARDS RISK ASSESSMENT

REGULATION: [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. *[For LTC facilities at §483.73(a)(1):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a)(1):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a)(2):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: September 28, 2018
Corrected date: October 18, 2018

Citation Details

Based on interview and record review during the Emergency Preparedness Plan review, in conjunction with the Life Safety Code survey completed on 9/28/18, it was determined the facility Emergency Preparedness Plan did not comply with emergency preparedness requirements. Specifically, the facility's Emergency Preparedness Plan, did not assess facility-based or community-based risks and vulnerability levels of potential hazards, utilizing an all-hazards approach. The finding is: On 9/27/18, a review of the facility's Disaster and Evacuation Policy and Procedures manual with a review date of (MONTH) (YEAR), revealed the manual contained no documentation that facility-based and community-based risk assessments, utilizing an all-hazards approach, had been conducted for the facility's Emergency Preparedness Plan. During an interview on 9/27/18 at 12:52 PM the Administrator and Director of Facilities stated the Disaster and Evacuation Policy and Procedures manual was the facility's emergency preparedness plan. The Administrator and Director of Facilities further stated a facility based and community based risk assessments, utilizing an all-hazards approach, were not completed for the facility as part of the Disaster and Evacuation Policy and Procedures. 42 CFR 483.73-Emergency Preparedness 483.73(a)(1)(2)

Plan of Correction: ApprovedOctober 18, 2018

E006
Plan based on all hazards risk assessment:
1. The facility will review the current emergency preparedness plan and make necessary corrections to comply with the emergency preparedness requirements.
2. The facility will complete facility-based and community-based risk assessments using an all-hazards approach.
3. The facility based and community based risk assessment was developed and will be reviewed annually by the QAA committee in December, (YEAR) to ensure that all risk assessments are accurate and complete.
4. Overall responsibility to ensure action is implemented is with the Director of Facilities/designee. Completion date is 10/18/2018

ROLES UNDER A WAIVER DECLARED BY SECRETARY

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: September 28, 2018
Corrected date: October 18, 2018

Citation Details

Based on interview and record review during the Emergency Preparedness Plan review, in conjunction with the Life Safety Code survey completed on 9/28/18, it was determined the facility Emergency Preparedness Plan did not comply with emergency preparedness requirements. Specifically, the facility's Emergency Preparedness Plan did not contain documentation describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver. The finding is: On 9/27/18, a review of the facility's Disaster and Evacuation Policy and Procedures manual with a review date of (MONTH) (YEAR), revealed the manual contained no documentation describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver. On 9/27/18 at 1:49 PM the Administrator and the Director of Facilities stated, the Disaster and Evacuation Policy and Procedures manual was the facility's emergency preparedness plan. The Administrator and the Director of Facilities further stated, the Disaster and Evacuation Policy and Procedures manual did not contain documentation describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver. Per Centers for Medicare and Medicaid Services (CMS) The Emergency Preparedness Rule requires that some providers have policies and procedures, which address the role of the facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. This may include policies and procedures on what a facility would do if they had to provide care at an approved alternate site as well as processes on how would they let the community know they are operating at a different care site and any reporting they may need to do if they were under an approved 1135 Waiver. 42 CFR 483.73-Emergency Preparedness 483.73(b)(8)

Plan of Correction: ApprovedOctober 18, 2018

E026
Emergency Preparedness - Roles under a waiver declared by secretary
1. The facility will review the current emergency preparedness plan and make the necessary modifications.
2. The facility will develop documentation describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver. This will include policies and procedures on what(NAME)Run will do if we have to provide care at an approved alternate site as well as processes on how we would let the community know that we were operating at a different care site and any reporting necessary under an approved 1135 waiver.
4. Documentation pertaining to the facility's role in providing care and treatment at an alternate site under a 1135 waiver will be reviewed initially by the QAA committee at our December, (YEAR) meeting and annually thereafter.
5. Overall responsibility to ensure action is implemented is with the Director of Facilities/designee. Completion date is 10/18/2018

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 28, 2018
Corrected date: October 18, 2018

Citation Details

Based on observation, interview, and record review during a Life Safety Code survey completed on 9/28/18, the building's automatic sprinkler system was not properly maintained. Issues included, one (fire department connection located near the front entrance of the building) of the building's two fire department connections was obstructed. This affected one (Second Floor of the Health Center) of one resident unit. The finding is: 1) Observations on the exterior of the building, on 9/25/18 at 8:30 AM and 11:51 AM, revealed a six-foot long by five-foot wide picnic table, with benches attached to it, was stored directly in front of and obstructing the fire department connection located near the front entrance of the building. During an interview on 9/25/18 at 11:51 AM, the Director of Facilities and the Facilities Supervisor stated the picnic table was not normally stored in front of the fire department connection and it should not have been stored in front to the fire department connection. The Director of Facilities and the Facilities Supervisor further stated the picnic table had been moved and stored in front of the fire department connection the previous night due to the weather forecast for high winds. During an interview on 9/27/18 at 9:37 AM, the Director of Facilities stated daily rounds of the building were conducted and documented by members of the maintenance staff on the Second Shift (3:00 PM to 11:00 PM). The Director of Facilities further stated, the rounds were conducted to ensure there were no issues with the building. Review of Second Shift daily rounds sheets dated 9/22/18, 9/23/18, 9/24/18, 9/25/18, and 9/26/18 revealed they contained no documentation about the building's fire department connections. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 9.7.5 2011 NFPA 25: 13.7.1(1)

Plan of Correction: ApprovedOctober 18, 2018

K353
NFPA 101 - Sprinkler System Maintenance and Testing
1. The facility will follow NFPA 25 standard for Sprinkler system testing and maintenance.
2. The Director of Facilities and Maintenance Department immediately removed the picnic table that was placed in front of and obstructing the fire department connection located near the front entrance of the building.
3. Mandatory Fire Safety In-services were held in mid-October, (YEAR) to educate all staff that entrance/exit doors must be free of any obstruction.
4. The Director of Facilities immediately instructed his Maintenance staff to check all entrance/exit doors for obstruction during their daily rounds. This item was also added to our Maintenance Departments Daily Rounds Checklist. The checklist is audited on a weekly basis by the Director of Facilities/designee. Audits will be brought to the QAA committee in December, (YEAR) and on a quarterly basis for review and need for continuance.
5. Overall responsibility to ensure action is implemented and maintained is with the Director of Facilities/designee. Completion date is 10/18/2018.

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 28, 2018
Corrected date: September 29, 2018

Citation Details

Based on observation, interview, and record review during a Life Safety Code survey completed on 9/28/18, smoke barrier walls were not properly maintained. Issues included, smoke barrier walls were not complete from floor to ceiling/ roof deck, were not designed to have at least a 30-minute fire resistance rating, and were not designed to resist the passage of smoke, due to unsealed penetrations. This affected one (Second Floor of the Health Center) of one resident unit. The findings are: 1) a) Observation above the corridor ceiling tiles on the Second Floor, on 9/25/18 at 1:40 PM, revealed a one-inch circular penetration below two blue electrical wires that were installed through the smoke barrier wall above the smoke barrier doors near Resident Room #436. During the observation, the Director of Facilities stated the wires had been installed a week ago for the building's communication system. b) Observation above the corridor ceiling tiles on the Second Floor, on 9/25/18 at 2:08 PM, revealed a one-half inch circular penetration around a two-inch wide bundle of six blue electrical wires that had been installed through the smoke barrier wall above the smoke barrier doors near Resident Room #401. During the observations the Director of Facilities stated he was not sure what system the wires were installed for. c) Observation above the corridor ceiling tiles on the Second Floor, on 9/25/18 at 2:24 PM, revealed a two-foot long by ten-inch wide penetration around five electrical conduits that had been installed through the smoke barrier wall above the smoke barrier doors near Resident Room #422. During the observation, the Director of Facilities stated the conduits had been installed by an outside contractor as part of the building's construction project and the last time the contractor had worked in this area of the building was a week and a half ago. During an interview on 9/27/18 at 9:37 AM the Director of Facilities stated, daily rounds of the building were conducted and documented by members of the maintenance staff on the Second Shift (3:00 PM to 11:00 PM). The Director of Facilities further stated, the rounds were conducted to ensure there were no issues with the building. Review of Second Shift daily rounds sheets dated 9/22/18, 9/23/18, 9/24/18, 9/25/18, and 9/26/18 revealed they contained no documentation about penetrations through the Second Floor smoke barrier walls. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101:19.3.7, 19.3.7.3, 8.5, 8.5.1, 8.5.2, 8.5.2.1, 8.5.2.2

Plan of Correction: ApprovedOctober 22, 2018

K372
Subdivision of Building Spaces - Smoke Barriers
1. The facility will ensure that smoke barriers are properly maintained and have at least a 30-minute fire resistance rating and will resist the passage of smoke.
2. The Maintenance Department immediately sealed all penetrations in the following areas: above smoke barrier doors near Room #436, above smoke barrier doors near Room #401, and above smoke barrier doors near Room #422.
3. The Director of Facilities immediately instructed all Maintenance staff to check for penetrations above smoke barrier doors during the daily rounds. This item was also added to our Maintenance Departments Daily Rounds Checklist. The checklist is audited on a weekly basis by the Director of Facilities/designee. Audits will be brought to the QAA committee in December, (YEAR) and on a quarterly basis for review and need for continuance.
5. Overall responsibility to ensure action is implemented and maintained is with the Director of Facilities/designee. Completion date is 9/29/2018.

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 28, 2018
Corrected date: September 29, 2018

Citation Details

Based on observation, interview, and record review during a Life Safety Code survey completed on 9/28/18, vertical openings were not properly maintained. Issues included, a stairway was not enclosed with construction having a fire resistance rating of at least one hour. This affected one (Second Floor of the Health Center) of one resident unit. The finding is: Observation on the Second Floor, in the Stair 3 stairway, on 9/25/18 at 9:46 AM, revealed a one-half-inch penetration around a one-half-inch metal electrical conduit that was installed through the block wall that separated the Stair 3 stairway from the Second Floor corridor. Further observation at this time revealed a one-half-inch penetration around the conduit where it was installed through the block wall that separated the Stair 3 stairway from the First Floor corridor. During an interview on 9/25/18 at 2:37 PM the Director of Facilities stated, the conduit had been installed through the wall approximately one year ago. The Director of Facilities further stated, the conduit had been installed to supply power to the emergency generator's remote annunciator panel. During an interview on 9/27/18 at 9:37 AM the Director of Facilities stated, daily rounds of the building were conducted and documented by members of the maintenance staff on the Second Shift (3:00 PM to 11:00 PM). The Director of Facilities further stated, the rounds were conducted to ensure there were no issues with the building. Review of Second Shift daily rounds sheets dated 9/22/18, 9/23/18, 9/24/18, 9/25/18, and 9/26/18 revealed they contained no documentation about the penetrations in the Stair 3 stairway walls. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.1, 19.3.1.1, 8.6.2

Plan of Correction: ApprovedOctober 22, 2018

K311
Vertical Openings
1. The facility will ensure that vertical openings will be maintained as per NFPA 101.
2. The Maintenance Department immediately sealed the penetration in the block wall in Stair 3 using fire caulk with a resistance rating of (1) one hour.
3. A 100% audit of vertical openings in the Skilled Nursing Facility was completed on 9/25/2018 to ensure there were no other unsealed penetrations.
4. The Director of Facilities immediately instructed his Maintenance staff to check vertical openings for penetrations during their daily rounds. This item was also added to our Maintenance Departments Daily Rounds Checklist immediately. The checklist is audited on a weekly basis by the Director of Facilities/designee. Audits will be brought to the QAA committee in December, (YEAR) and on a quarterly basis for review.
5. Overall responsibility to ensure action is implemented and maintained is with the Director of Facilities/designee. Completion date is 9/29/2018