St Luke Residential Health Care Facility Inc
January 17, 2019 Certification/complaint Survey

Standard Health Citations

FF11 483.60(i)(1)(2):FOOD PROCUREMENT,STORE/PREPARE/SERVE-SANITARY

REGULATION: §483.60(i) Food safety requirements. The facility must - §483.60(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. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 18, 2019
Corrected date: March 19, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety in 4 of 6 kitchenettes (Units 5, 6 and 7). Specifically, multiple kitchenette refrigerators contained items that were outdated or were not labeled. Findings include: The Food Service On-Unit Refrigerator policy, dated [DATE], documented Residents items must be labeled with the resident's name and room number and dated when the item is being stored. Items must be used within three days or will be thrown away, and Any unlabeled or undated items will be thrown out by the Food Service staff when they stock the refrigerators. The undated kitchen task assignments included a position that was designated to one employee and this position will be fully responsible to maintain, clean and stock the kitchenette on the Wings daily. The sheet continued to document that refrigerators were to be cleaned and all out dated items removed, to ensure items were properly labeled and dated, food items past three days (per policy) were to be discarded, open beverage items were to have open dates on them, and employee personal items were not allowed in the unit refrigerator. During an observation on [DATE] at 12:04 PM, the 2nd floor kitchenette refrigerator had an undated open container of cranberry juice, an open container of apple juice dated [DATE], and two open cartons of Med-Pass 2.0 (a nutritional supplement) dated [DATE]. On [DATE], between 12:44 PM and 1:05 PM, the following observations were made: - the Unit 5 kitchenette refrigerator contained an undated open container of French onion dip; - the Unit 6 kitchenette refrigerator contained an undated container of fried fish/shrimp/clams, and an unlabeled container of diced potatoes; - the Unit 7 kitchenette refrigerator contained an undated tuna sandwich, and an undated plastic container of macaroni and cheese. There was a Food Service On-unit Refrigerator policy and a food memo for all staff posted on all kitchenette refrigerators. On [DATE] at 1:00 PM, the Food Service Director stated someone from the kitchen staff was assigned every morning to check the kitchenette refrigerators and ensure that undated food items (drinks/food) were removed. He was not aware of any of the undated items observed on [DATE]. On [DATE] an undated food memo was observed in the unit kitchenettes and documented for all staff All items in refrigerator/freezer must be dated and labeled, and All items in refrigerator/freezer undated or unlabeled will be discarded. On [DATE] at 9:38 AM, the refrigerator in the Unit 2 kitchenette was observed with an undated open container of apple juice dated [DATE], and two open cartons of Med-Pass 2.0 dated [DATE]. The side of the Med Pass 2.0 container stated it was good for 4 days after opening. On [DATE] at 4:17 PM, the Food Service Manager stated the dates on the two Med Pass 2.0 containers and the two apple juice containers indicated when they were received by the facility, and there was no open date on the containers. During an interview with dietary staff #1 on [DATE] at 10:51 AM, she stated she was responsible for checking all refrigerators on resident units daily on her scheduled work days. She worked ,[DATE] to current. She stated anything that has an expired date was to be taken out of the refrigerator. She stated staff often put their personal food in the refrigerators without open dates and she would have to ask them who they belonged to and tell them they would have to be thrown away. She stated there should be an open date on items and if it was after 3 days she was to discard the items. She stated she did not use this date for items such as juice and would use the manufacturers expiration date on the item itself. 10NYCRR 415.14(h)

Plan of Correction: ApprovedMarch 7, 2019

PLAN OF CORRECTION
ST. LUKE HEALTH SERVICES
SURVEY EXIT DATE: 1/18/2019
F 812
483.60(i)(1)(2) Food Procurement,Store/Prepare/Serve-Sanitary
§483.60(i) Food safety requirements.
Preparation and/or execution of this plan do not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility?s credible allegation of compliance.
1. Corrective action(s) will be / have been accomplished for those residents found to be affected by the deficient practice:
2nd Floor Kitchenette Refrigerator: has been inspected by the Food Service Department. Any unlabeled / outdated items have been discarded. Completion Date: 2/4/2019 and ongoing
5th Floor Kitchenette Refrigerator: has been inspected by the Food Service Department. Any unlabeled / outdated items have been discarded. Completion Date: 2/4/2019 and ongoing
6th Floor Kitchenette Refrigerator: has been inspected by the Food Service Department. Any unlabeled / outdated items have been discarded. Completion Date: 2/4/2019 and ongoing
7th Floor Kitchenette Refrigerator: has been inspected by the Food Service Department. Any unlabeled / outdated items have been discarded. Completion Date: 2/4/2019 and ongoing

2. Identification of other residents having the potential to be affected by the same deficient practice and corrective action taken:
All on unit Kitchenette Refrigerators have been inspected by the Food Service Department. Any unlabeled / outdated items have been discarded. Completion Date: 2/8/2019 and ongoing
3. Measures put in place to ensure that the deficient practice does not recur:
The Memo in regards to ?All items in the refrigerator/freezer must be dated and labeled? will be revised to clarify the labeling system for items in the kitchenette refrigerator and a date will be added to the memo. Completion Date: 3/19/2019 and ongoing
Policy on On-Unit Refrigerators will be revised to include reference to the Memo that is posted on the Kitchenette Refrigerators. Completion date: 3/19/2019 and ongoing
All staff will be in-serviced by the In-service Coordinator in regards to the revised On-Unit Refrigerators policy and procedure as well as the Memo that is posted on the Kitchenette Refrigerators. Completion Date: 3/19/2019 and ongoing
4. How the Corrective Actions will be monitored by to ensure the practice will not recur:
A QA monitor will be implemented to ensure items in the on-unit kitchenette refrigerators do not have unlabeled / outdated items in them The audit will be done monthly for three months, then quarterly for six months by Food Service Director / Designee with further frequency of monitoring to be determined by the QA committee. Expected Number of Refrigerators to be audited: Three (3) on unit kitchenette refrigerators on the day shift and three (3) on unit kitchenette refrigerators on the evening shift will be audited per week. Expected Threshold: 85%. Completion Date: 3/19/2019 ongoing
5. Date for Correction: 3/19/2019 and ongoing
6. Person Responsible for Correction: Food Service Director / Designee

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 18, 2019
Corrected date: March 19, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey the facility did not ensure 1 of 6 residents (Resident #106) reviewed for range of motion (ROM), received appropriate services and equipment to maintain or improve mobility. Specifically, Resident #106 was not provided with assistive devices for hand contractures (stiffness in the connective tissues) as care planned. Findings include: Resident #106 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 11/26/18 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, was totally dependent for all activities of daily living (ADLs), and had impaired range of motion on bilateral (both sides) upper extremities. The 1/13/14 comprehensive care plan documented the resident had bilateral hand contractures. The undated revision documented the resident was to have bilateral carrot hand splints applied after morning care for 4 hours, removed for lunch, reapplied at 2:00 PM for four hours, then removed. The 6/26/18 Occupational Therapy (OT) Evaluation and Plan of Treatment documented the resident had contractures to the left and right hands. The resident was evaluated by OT for assessment of splints and a wearing schedule for the most appropriate splints. The evaluation documented the following: - The resident had contractures to both hands which needed splints; - The resident required reassurance and gentle joint range of motion while applying the splits; - Carrot splints fit in both hands; - Staff would have to take time to apply the splints gently and reassure the resident during application; and - Splints were to be applied for four hours twice a day. The 6/27/18 physician order [REDACTED]. The 1/8/19 updated resident care record (RCR) documented the resident was to have bilateral carrot splits placed with morning care for four hours, remove for lunch, replace at 2:00 PM for four hours, then removed. The (MONTH) 2019 treatment administration record (TAR) documented the resident's carrots splints were in place from 8:00 AM to 12:00 PM on 1/16/19 and 1/17/19 by licensed practical nurse (LPN) #35 and from 2:00 PM to 6:00 PM on 1/15/19, 1/16/19, and 1/17/19 by LPN #33. A refusal was documented on 1/15/19 at 8:00 AM to 12:00 PM with no reason noted. On 1/15/19 at 4:44 PM, the resident was observed without a carrot in her right hand which was closed in a fist. On 1/16/19 at 10:10 AM, the resident was observed without a carrot in her right hand and her hand was contracted into a fist. At 10:38 AM, both hands were observed without carrots in place. On 1/16/19 at 2:00 PM, the resident had no carrots in either hand. Both hands were contracted into fists. On 1/17/19 at 9:08 AM and at 10:35 AM, the resident was observed with her right hand contracted into a fist and she did not have a carrot in place. On 1/17/19 at 3:56 PM, the resident was observed without carrots in either hand. Per the 1/17/19 assignment sheet, certified nurse aide (CNA) #34 was responsible for the resident during the day and CNA #32 was assigned to the resident for the evening. When interviewed on 1/17/19 at 4:30 PM, CNA #31 stated a resident's contracture devices such as carrots were documented on the RCR and it was the CNA's responsibility to put them in place. She stated the resident has had carrots in the past, her hands were tight, and the carrots were hard to place at times. When interviewed on 1/17/19 at 4:35 PM, CNA #32 stated the RCR documented if the resident needed carrots and she checked it everyday. The CNA was assigned to the resident on that day and she stated she forgot to put the carrots in the resident's hand. When interviewed on 1/17/19 at 4:40 PM, LPN #33 stated the CNA was responsible for placing the carrot and if they were unable to, she would try to place them. She stated the CNA was responsible for documenting and she did not document on the carrots. The LPN stated the resident had the carrots in for 30 minutes that afternoon and she personally attempted to place them. She stated that a CNA was trying at that moment to place the carrots. At that time, CNA #31 stated she was able to place the carrots with some difficulty. When interviewed on 1/18/19 at 9:01 AM, CNA #34 stated the CNA was responsible for putting carrots in place and the LPN was responsible for checking if the carrots were in place. She stated she was assigned to the resident that day and the resident used to have carrots ordered but not anymore. The resident received morning care from the night shift who would be responsible for putting them in and the day shift would make sure they were in after breakfast. She stated she had not put the resident's carrots in for a while. When interviewed on 1/18/19 at 9:09 AM, LPN #35 stated if the night shift did not place the carrots after morning care, the day shift would be responsible for placing them when they took over for the resident. She stated she signed off on all her treatments yesterday and did not check to see if the resident had them in place. When interviewed on 1/18/19 at 9:14 AM, the registered nurse (RN) unit manager #28 stated the resident was scheduled to have carrots every day and it was documented on the resident's RCR. The RN stated the resident received morning care on the night shift and they should be placing the carrots. If the night shift did not place the carrots, she would expect the day shift to place the carrots when they took over care for the resident. She said if the CNA or LPN signed off on the care or treatment, the carrots should be in place. The resident needed the carrots because her hands were really contracted and it allowed air to get to her hands to protect the skin. When interviewed on 1/18/19 at 9:35 AM, OT #25 stated she expected nursing staff to follow through with orders for carrot splints. She stated the resident had carrots for contractures in both hands which allowed the hands to be in a more open position mostly for skin integrity. The resident needed the carrots and she expected staff to place them as ordered.
10NYCRR 415.12(e)(2)

Plan of Correction: ApprovedMarch 7, 2019

PLAN OF CORRECTION
ST. LUKE HEALTH SERVICES
SURVEY EXIT DATE: 1/18/2019
F 688
483.25(c)(1)-(3) Increase/Prevent Decrease in ROM/Mobility
§483.25(c) Mobility.
§483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and
Preparation and/or execution of this plan do not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility?s credible allegation of compliance.
1. Corrective action(s) will be / have been accomplished for those residents found to be affected by the deficient practice:
Resident #106: On 2/1/2019 Occupational Therapist and Unit Manager met and discussed
Carrott Splints wearing schedule. Unit Manager verified the order with NP for the splints and is as follows: Apply bilateral Carrott Splints to bilateral hands after AM care, remove at breakfast, reapply after lunch and remove at suppertime as tolerated, RCR only. The Resident Care Record and plan of care has been updated. Completion Date 2/1/2019 and ongoing.
2. Identification of other residents having the potential to be affected by the same deficient practice and corrective action taken:
All residents with hand splints will be reviewed by the Director of Therapy / Designee to ensure hand splints continue to be appropriate and wearing times are appropriate. Physician orders, comprehensive care plans and resident care records will be revised as needed. Completion Date: 3/19/2019 and ongoing
3. Measures put in place to ensure that the deficient practice does not recur:
All Nursing staff will be in-serviced by the In-service Coordinator regarding following the physician order, resident plan of care and resident care record as it relates to hand splint use. Completion Date: 3/19/2019 and ongoing.
4. How the Corrective Actions will be monitored by to ensure the practice will not recur:
A QA monitor will be implemented to ensure residents who have hand splints have the splints placed per the physician order, comprehensive plan of care, resident care record and are observed wearing the hand splint during the scheduled times. The audit will be done monthly for three months, then quarterly for six months by Director of Rehab / Designee with further frequency of monitoring to be determined by the QA committee. % of Residents to be Audited Monthly: 10% of the in-house residents wearing hand splints on the day shift and 10% of the in-house residents wearing hand splints on the evening shift will be audited each month. Expected Threshold: 85%. Completion Date: 3/19/2019 and ongoing.
5. Date for Correction: 3/19/2019 and ongoing
6. Person Responsible for Correction: Director of Rehab / Designee

FF11 483.25:QUALITY OF CARE

REGULATION: § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 18, 2019
Corrected date: March 19, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey, the facility did not ensure 1 of 1 resident (Resident #29) reviewed for skin conditions, received treatment and care in accordance with professional standards of practice. Specifically, Resident #29 sustained a skin tear to her leg and there were no ordered treatments or care planned interventions to promote healing. Findings include: Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 1/8/19 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, no wounds or skin problems, had a pressure reducing device for chair and bed and received application of ointments/medications for skin treatments. The comprehensive care plan (CCP) initiated 1/13/17 and reviewed on 10/15/18, documented the resident was at high risk for skin breakdown and did not have any skin impairments. Interventions included an air mattress and a gel foam cushion to the resident's wheelchair. A nursing progress note documented on 12/04/18, the resident had a skin tear, with scant blood, to the left lower leg measuring 1.0 centimeter (cm) x 0.7 cm. The wound was cleansed and silicone tape was applied. There were no corresponding physician orders [REDACTED]. Weekly nursing skin assessments by RN #19 dated 12/28/18 and 1/4/19 documented the resident's skin was clean, dry and intact with no redness or open areas. The nurse drew a line through the area before her signature. Both dates had scab to LLE healing written in on the line before the signature and were not present during the initial record review on 1/16/19. A weekly nursing skin assessment by RN #19 dated 1/15/19 documented the resident's skin was clean, dry and intact, there was no redness or open areas. The nurse drew a line through the area before her signature. Below the line and signature was written scab to LLE healing which was not present during initial record review on 1/16/19. The resident was observed: - On 01/15/19 at 02:08 PM with a black scabbed indentation on the left outer leg above the ankle. - On 01/16/19 at 08:55 AM with swelling and redness around the scabbed area of the left leg. - On 01/16/19 at 03:17 PM with a soaked bandage hanging off the left leg wound. The left leg remained swollen and red. - On 01/17/19 at 04:43 PM with a bandage/dressing on the left leg. During a wound observation and interview on 1/16/19 at 9:10 AM with licensed practical nurse (LPN) #10, the resident had a scabbed area on her left lower lateral leg measuring 1.0 cm x 1.0 cm with [MEDICAL CONDITION] (indentation when pushed in) and redness around the scabbed area. The area was tender to touch and the resident recoiled and cried out when the LPN pressed on her skin. The LPN stated the resident had sustained a skin tear on 12/04/18 and had a history of [REDACTED]. During an interview with LPN #20 on 1/17/19 at 12:11 PM, she stated she was aware the resident had a scab on her left lower leg, but she thought it was healing. She stated the resident would often bang her legs on the furniture or on her wheelchair but they did not have anything in place on the care plan except for the pad on the wheelchair. She stated that she did not know the resident's wound was not healing, or was so swollen. She stated they had no wound/skin care orders in place before 1/16/18 and it was not in the care plan. During an interview on 1/17/19 at 11:08 AM, registered nurse (RN) Unit Manager #19 stated the resident had a scab on her leg for some time, and she often had [MEDICAL CONDITION]. She stated she did not notice any redness or increasing swelling and she did not know the resident had any pain in her left leg. She stated the last time the skin care plan was updated was on 10/15/18. She stated that it should have been updated 12/04/18 after the resident got injured. She stated the resident's legs could have been elevated and since she has been scooting herself in her wheelchair, a referral for physical therapy (PT) may have been useful. She added that she should have called the nurse practitioner or physician for a wound consult since the wound was not healing. When asked if she had added scab to LLE healing after she had written her notes on 12/28/18, 1/4 and 1/15/19 she did not answer. During an interview on 1/17/19 at 12:37 PM, CNA #22 stated skin observations were done during AM care daily and during toileting and showers. She stated she noticed the resident's left leg [MEDICAL CONDITION] and swelling last week and stated she reported it to the LPN but she did not document it. She stated she did not elevate the resident's legs because it did not say to do so on the resident's care instructions. 10NYCRR 415.2

Plan of Correction: ApprovedMarch 7, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** PLAN OF CORRECTION
ST. LUKE HEALTH SERVICES
SURVEY EXIT DATE: 1/18/2019
F684
483.25 Quality of Care
§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Preparation and/or execution of this plan do not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility?s credible allegation of compliance.
1. Corrective action(s) will be / have been accomplished for those residents found to be affected by the deficient practice:
Resident #29: The NP assessed the resident?s skin on 1/16/2019 and prescribed a treatment for [REDACTED]. On 1/17/2019 the NP again assessed the area as the scab had come off. Treatment prescribed was D/C [MEDICATION NAME] and band aid to LLE ? start Solosite and dry dressing to left lower extremity. Elevate leg above heart as resident tolerates. On 1/23/19 the NP reassessed the area and d/c?d the treatment as no further treatment was indicated at this time. 2/1/2019 RN Unit Manager added Derma sleeves to bilateral legs when OOB to resident?s plan of care and resident care record as resident self-propels in room and has decreased vision. Completion Date: 2/1/2019 and ongoing
2. Identification of other residents having the potential to be affected by the same deficient practice and corrective action taken:
The RN Unit Manager will review all resident?s medical record progress notes since 1/18/2019 for resident?s who had had a skin tear to ensure the injuries were assessed by a qualified professional, a physician order [REDACTED].
to promote healing. Completion Date: 3/19/2019 and ongoing.
All in-house residents will have a skin assessment completed by the RN Unit Manager / Designee to ensure any skin tear(s) has been identified, assessed by a qualified professional, a physician order [REDACTED]. Completion Date: 3/19/2019 and ongoing.
3. Measures put in place to ensure that the deficient practice does not recur:
All nursing staff will be educated by the In-Service Coordinator in regards to reporting any skin tear to the appropriate qualified individual so that the area can be to assessed, appropriate treatment orders are in place or obtained from the physician / physician extender or have care planned interventions to promote healing put into place. Completion Date: 3/19/2019 and ongoing
All licensed nursing staff will be educated by the In-Service Coordinator in regards to the documentation and assessment requirements of residents with skin tears. This will include ensuring a RN or other qualified professional has assessed the resident?s skin tear and there is documentation of physician orders [REDACTED]. Completion Date: 3/19/2019 and ongoing
4. How the Corrective Actions will be monitored by to ensure the practice will not recur:
A QA monitor will be implemented to ensure resident(s) who have sustained skin tear(s) are assessed by an RN/ qualified individual, have treatment orders in place or are obtained from the physician / physician extender, or have care planned interventions to promote healing in place. The audit will be done monthly for three months, then quarterly for six months by Employee Health Nurse / Designee with further frequency of monitoring to be determined by the QA committee. Number of Skin Tears to be Reviewed Monthly: Four per unit monthly (20). Expected Threshold: 85%. Completion Date: 3/19/2019 and ongoing.
5. Date for Correction: 3/19/2019 and ongoing
6. Person Responsible for Correction: Director of Nursing / Designee

FF11 483.10(c)(6)(8)(g)(12)(i)-(v):REQUEST/REFUSE/DSCNTNUE TRMNT;FORMLTE ADV DIR

REGULATION: §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. §483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate. §483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law. (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 18, 2019
Corrected date: March 19, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the recertification survey, the facility did not ensure 2 of 6 residents (Residents #62 and 106) reviewed for advance directives, had the right to formulate advance directives. Specifically, Residents #62 and 106 had Medical Orders for Life-Sustaining Treatment (MOLST) completed by a health care proxy (HCP, a person designated to make health care decisions for someone determined to lack capacity for decision making) and there was no documentation the residents lacked decision-making capacity. Findings include: The (MONTH) (YEAR) Resuscitation Orders and Health Care Proxy Policy documented when the attending physician determined the resident/patient lacked the capacity to make a DNR (do not resuscitate) decision, a concurring physician's assessment would be sought. 1) Resident #62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 9/2/14 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition and required extensive assistance for all activities of daily living. The 8/26/14 physician orders [REDACTED]. The 8/29/14 MOLST form documented the resident was a do not resuscitate (DNR, allow natural death), do not intubate (DNI), and comfort measures only. The form was signed by the resident's Health Care Proxy (HCP). There was no documentation the resident had a determination of capacity completed by the attending physician and a concurring physician or nurse practitioner. 2) Resident #106 was admitted on [DATE] with [DIAGNOSES REDACTED]. The 1/20/14 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition. The 1/13/14 comprehensive care plan (CCP) documented the resident was to receive palliative care. The 1/14/14 MOLST documented the resident was a do not resuscitate (DNR, allow natural death), do not intubate (DNI), and comfort measures only. The resident's HCP provided verbal consent for the orders. The 7/14/14 physician order [REDACTED]. There was no documentation the resident had a determination of capacity completed by the attending physician and a concurring physician or nurse practitioner. When interviewed on 1/18/19 at 9:42 AM, the Director of Social Services stated the physician determined if a resident had capacity to make health care decisions during their initial visit. If a resident lacked capacity, the facility had a form that two providers had to complete and a copy should be in the chart. She stated she would expect the resident to have a lack of capacity in the chart and capacity had to be determined prior to completing the MOLST. She stated this was the responsibility of the nurses and the physicians and social work would double check the forms. When interviewed on 1/18/19 at 9:54 AM, the registered nurse (RN) Unit Manager #27 stated the physician determined if the resident had capacity to make health care decisions. She stated there was not a form to fill out and the physician would document capacity in his note. She stated they had not been getting a second concurring physician or practitioner to determine capacity. The RN stated the resident did not have capacity to make advance directive decisions. When interviewed on 1/18/19 at 9:59 AM, the registered nurse (RN) Unit Manager #28 stated she was familiar with the procedure for lack of capacity requiring two concurring physicians and she did not think it was done at the facility. She stated the physician would determine capacity during the initial visit and the unit manager would provide the Lack of Capacity form for the physician to sign. The social worker would check the form. The form should be in the resident's chart. When interviewed on 1/18/19 at 10:05 AM, nurse practitioner (NP) #29 stated the physician determined capacity of the resident on admission. With the electronic MOLST, two physicians were needed to determine capacity. The NP stated the physician never asked her to determine a resident's capacity. When interviewed on 1/18/19 at 10:39 AM, physician #30 stated he initiated advance directives during his first visit and determined capacity at that time. He had not seen the lack of capacity form in a while and he would expect the Unit Manager to provide the form for him. 10NYCRR 415.3(e)(2)(iii)

Plan of Correction: ApprovedMarch 7, 2019

PLAN OF CORRECTION
ST. LUKE HEALTH SERVICES
SURVEY EXIT DATE: 1/18/2019
F578
483.10(c)(6)(8)(g)(12)(i)-(v) Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir
§483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Preparation and/or execution of this plan do not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility?s credible allegation of compliance.
1. Corrective action(s) will be / have been accomplished for those residents found to be affected by the deficient practice:
Resident #62: An Adult without Capacity Form has been completed Completion Date: 2/8/2019
Resident #106: An Adult without Capacity Form has been completed Completion Date: 2/8/2019
2. Identification of other residents having the potential to be affected by the same deficient practice and corrective action taken:
All resident records with advance directives will be reviewed by the RN Unit Manager / Designee to ensure they have a capacity form in place. Those identified as not having one will have the appropriate capacity form completed. Completion Date: 3/19/2019 and ongoing.
3. Measures put in place to ensure that the deficient practice does not recur:
The Resuscitation Orders / Health Care Proxy policy and procedure will be revised to ensure it includes the Adult with Capacity and Adult without Capacity Forms for completion prior to initiating an Advance Directive. Completion Date: 3/19/2019 and ongoing
All RN?s, Social Workers and Medical Staff will be in-serviced by the Social Service Director / In-service Director / Designee in regards to the revised Resuscitation Orders / Health Care Proxy policy and procedure. Completion Date: 3/19/2019 and ongoing.
4. How the Corrective Actions will be monitored by to ensure the practice will not recur:
A QA monitor will be implemented to ensure Advance Directives are not formulated until a capacity form is completed. The audit will be done monthly for three months, then quarterly for six months by Social Service Director / Designee with further frequency of monitoring to be determined by the QA committee. Number of Records to be Audited Monthly: All New Admissions and 10 in-house resident records will be audited monthly. Expected Compliance: 85%. Completion Date: 3/19/2019 and ongoing
5. Date for Correction: 3/19/2019 and ongoing
6. Person Responsible for Correction: Director of Social Work / Designee

Standard Life Safety Code Citations

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2019
Corrected date: March 18, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview conducted during the Life Safety Code survey, the facility did not properly maintain electrical installations for 5 isolated areas (resident room [ROOM NUMBER], staff dining room, Internet Technology, 1A nursing station, and 1B nursing station). Specifically, unapproved electrical adapters were used in the above referenced areas. Findings include: On 1/15/19 at 12:43 PM, in resident room [ROOM NUMBER], a lighted holiday tree plugged into an unapproved extension cord was observed. On 1/16/19 at 11:53 AM, in the staff dining room an unapproved 6-prong adaptor with nothing plugged into it was observed. The adaptor had a label that read, please return to maintenance department. During an interview on 1/16/19 at 3:16 PM, the Maintenance Director stated he was not aware of the unapproved adaptors found during survey. On 1/16/19 at 3:58 PM, in the Internet Technology office, a 10-prong adaptor strip plugged into another 10-prong adaptor strip was observed. A computer and monitor were plugged into it and they were daisy chained together. On 1/17/19 at 2:38 PM, an unapproved 6-prong adaptor was observed behind the 1A nursing station. Immediately afterwards an unapproved 6-prong adaptor was observed behind the 1B nursing station. Both adaptors were being utilized for miscellaneous equipment at the time of the observation. 2012 NFPA 99: 10.2.4 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedMarch 7, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** PLAN OF CORRECTION
ST. LUKE HEALTH SERVICES
SURVEY EXIT DATE: 1/17/2019
K920 - NFPA 101 Electrical Equipment - Power Cords and Extens
Preparation and/or execution of this plan do not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility?s credible allegation of compliance.
1. Corrective action(s) will be / have been accomplished for those residents found to be affected by the deficient practice:
room [ROOM NUMBER]: Holiday tree with extension cord. The extension cord has been removed. Completion Date: 1/17/2019
Staff Dining Room: 6-prong adaptor has been removed. Completion Date: 1/17/2019
Internet Technology: Each 10 prong adaptor strip has been plugged into their own electrical outlet. Completion Date: 1/16/2019
1A Nurses Station: 6-prong adaptor has been removed. Completion Date: 1/17/2019
1B Nurses Station: 6-prong adaptor has been removed. Completion Date: 1/17/2019
Small Room Behind the Front Lobby Desk: 6-prong adaptor has been removed. Completion Date: 1/17/2019

2. Identification of other residents having the potential to be affected by the same deficient practice and corrective action taken:
The Maintenance Department will complete a full building inspection to ensure that all electrical installations (power strips and extension cords) meet proper Life Safety Code and are being used according to appropriate guidelines. Completion Date: 3/18/2019 and ongoing
3. Measures put in place to ensure that the deficient practice does not recur:
All staff will be in-serviced by the Building Engineer / In-service Coordinator in regards to the proper use of power strips and extension cords according to Life Safety Code and according to appropriate guidelines. Completion Date: 3/18/2019 and ongoing
Safety Tours will be completed monthly by the Safety Committee to ensure power strips and extensions cords are being used according to Life Safety Code and according to appropriate guidelines. Completion Date: 3/18/2019 and ongoing
The Maintenance Staff will complete quarterly inspections through-out the facility to ensure all power strips and extension cords meet Life Safety Code and are used according to appropriate guidelines. Date Completed: 3/18/2019 and ongoing
4. How the Corrective Actions will be monitored by to ensure the practice will not recur:
A QA monitor will be implemented to ensure all power strips and extension cords meet Life Safety Code and are being used according to guidelines. The audit will be done monthly for three months, then quarterly for six months by Building Engineer / Designee with further frequency of monitoring to be determined by the QA committee. Date Completed: 3/18/2019 and ongoing
5. Date for Correction: 3/18/2019 and ongoing
6. Person Responsible for Correction: Building Engineer / Designee

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2019
Corrected date: March 18, 2019

Citation Details

Based on observation, record review and interview during the Life Safety Code survey, the facility did not follow manufacturer's inspection recommendations for all testing and repairs of all patient care related electrical equipment in accordance with National Fire Protection Agency (NFPA) 99 for a hair dryer. Specifically, the facility did not follow the preventative maintenance guidelines set forth by the manufacturer for a hair dryer. Finding include: On 1/15/19 at 1:07 PM, a hair dryer located in the A-wing was observed without an inspection tag. During an interview on 1/17/19 at 3:19 PM, the Maintenance Director stated the A-wing hair dryer had never been brought to the attention of the maintenance department and had not been inspected as per facility policy. 2012 NFPA 99: 10.5.3 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedMarch 7, 2019

PLAN OF CORRECTION
ST. LUKE HEALTH SERVICES
SURVEY EXIT DATE: 1/17/2019
K921 - NFPA 101 Electrical Equipment - Testing and Maintenanc
Preparation and/or execution of this plan do not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility?s credible allegation of compliance.
1. Corrective action(s) will be / have been accomplished for those residents found to be affected by the deficient practice:
Hair Dryer A-Wing: The hair dryer has been inspected by the maintenance department and tagged. Completion Date: 1/16/2019
2. Identification of other residents having the potential to be affected by the same deficient practice and corrective action taken:
The Maintenance staff / Designee will complete a facility-wide building inspection to ensure patient care related electrical equipment (PCREE) meet the National Fire Protection Agency (NFPA) 99 and manufacture guidelines. Each will be tagged. Completion Date: 3/18/2019 and ongoing
3. Measures put in place to ensure that the deficient practice does not recur:
The Electrical Equipment policy and procedure will be revised to ensure that it meets the NFPA 99 guidelines for patient care related electrical equipment (PCREE). Completion Date: 3/18/2019 and ongoing
Safety Tours will be completed monthly by the Safety Committee to monitor to ensure patient care related electrical equipment (PCREE) are inspected and tagged by the maintenance department. Completion Date: 3/18/2019 and ongoing
The Maintenance Staff will complete quarterly inspections to ensure patient care related electrical equipment (PCREE) are inspected and tagged by the maintenance department to ensure they meet (NFPA) 99 and manufacture guidelines and will have a documentation system in place of this inspection that meets the guideline. Date Completed: 3/18/2019 and ongoing
All staff will be in-serviced by the Building Engineer / In-Service Coordinator on the revised Electrical Equipment policy and procedure to ensure they are educated on the National Fire Protection Agency (NFPA) 99 guidelines as it relates to patient care related electrical equipment (PCREE) and staff roles in compliance with the policy and procedure. Completion Date: 3/18/2019 and ongoing
4. How the Corrective Actions will be monitored by to ensure the practice will not recur:
A QA monitor will be implemented to ensure patient care related electrical equipment (PCREE) are inspected and tagged by the maintenance department to ensure they meet (NFPA) 99 and manufacture guidelines as well as a documentation system in place that meets the guideline. The audit will be done monthly for three months, then quarterly for six months by Building Engineer / Designee with further frequency of monitoring to be determined by the QA committee. Completion Date: 3/18/2019 and ongoing
5. Date for Correction: 3/18/2019 and ongoing
6. Person Responsible for Correction: Building Engineer / Designee

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

REGULATION: Electrical Systems - Essential Electric System Alarm Annunciator A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator. 6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99)

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2019
Corrected date: March 18, 2019

Citation Details

Based on observation and interview during the Life Safety Code survey, the facility did not ensure the emergency generator remote annunciator was properly installed for the generator. Specifically, the emergency generator did not have an alarm annunciator remotely installed in an area that had 24-hour staff coverage. Findings include: On 1/15/19 at 4:02 PM, the remote generator annunciator panel was observed located in the first floor main lobby switch board room. The first-floor also contained the nurse supervisor office, a chapel, other administrative offices, and at the end of a hallway were two resident care units (A wing and B wing). A fire barrier with double fire doors separated the A wing and B wing from the administrative area. During an interview on 1/15/19 at 4:37 PM, the Maintenance Director stated the switch board room was manned from 8:00 AM to 9:00 PM, and after 9:00 PM rounds were made by the nursing supervisor. By 9:00 PM there were no other administrative staff present on the first floor. On 1/16/19, between 3:16 PM and 3:30 PM, a surveyor stood in the hall outside the first floor A wing. At the same time the Maintenance Director placed the remote generator annunciator panel in test mode. The surveyor only heard a low dull ringing. During an interview on 1/15/19 at 4:37 PM, RN (registered nurse) Supervisor #18 stated: - she had worked until 12:00 AM and during her evening shift she could be anywhere in the facility; - the location of the remote generator panel was in the main lobby switch board room; - four days a week there were two supervisors on during the evening shift. When this occurred one supervisor would focus on the first floor, and one would focus on floors 2 through 7; and - during cold weather conditions the fire doors may be closed to keep the heat within the first floor A unit. On 1/16/19 at 3:52 PM, a surveyor stood inside the first floor A wing hall with the fire barrier double corridor doors closed. At the same time the Maintenance Director placed the remote generator annunciator panel in test mode and the surveyor could not hear the alarm. 2012 NFPA 99: 6.4.1.1.17 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedMarch 7, 2019

PLAN OF CORRECTION
ST. LUKE HEALTH SERVICES
SURVEY EXIT DATE: 1/17/2019
K916 - NFPA 101 Electrical Systems - Essential Electric Syste
Preparation and/or execution of this plan do not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility?s credible allegation of compliance.

1. Corrective action(s) will be / have been accomplished for those residents found to be affected by the deficient practice:
Remote Generator Annunciator Panel: The remote generator annunciator panel will be moved to 2nd floor nurses station so that it has 24 hour staff coverage. Completion Date: 3/18/2019 and ongoing
2. Identification of other residents having the potential to be affected by the same deficient practice and corrective action taken:
The Building Engineer/Designee will complete a full building inspection to ensure all generator annunciator panels are functioning properly. Date Completed: 3/18/2019 and ongoing
3. Measures put in place to ensure that the deficient practice does not recur:
All staff will be educated by the Building Engineer / In-Service Coordinator on the relocation, purpose of and their role as it relates to the remote generator annunciator panel. Completion Date: 3/18/2019 and ongoing.
The Building Engineer/Designee will perform weekly testing of the remote generator annunciator panel to ensure it functioning properly and staff know how to respond to the alarm. Completion Date: 3/18/2019 and ongoing
4. How the Corrective Actions will be monitored by to ensure the practice will not recur:
A QA monitor will be implemented to ensure the remote annunciator panel is functioning properly and staff know their role as it relates to the annunciator panel / alarms. The audit will be done monthly for three months, then quarterly for six months by Building Engineer / Designee with further frequency of monitoring to be determined by the QA committee. Completion Date: 3/18/2019 and ongoing
5. Date for Correction: 3/18/2019 and ongoing
6. Person Responsible for Correction: Building Engineer / Designee

K307 NFPA 101:MULTIPLE OCCUPANCIES - CONTIGUOUS NON-HEALTH

REGULATION: Multiple Occupancies - Contiguous Non-Health Care Occupancies Non-health care occupancies that are located immediately next to a Health Care Occupancy, but are primarily intended to provide outpatient services are permitted to be classified as Business or Ambulatory Health Care Occupancies, provided the facilities are separated by construction having not less than 2-hour fire resistance-rated construction, and are not intended to provide services simultaneously for four or more inpatients. Outpatient surgical departments must be classified as Ambulatory Health Care Occupancy regardless of the number of patients served. 18.1.3.4.1, 19.1.3.4.1

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2019
Corrected date: March 18, 2019

Citation Details

Based on observation and interview during the Life Safety Code survey, the facility did not ensure 1 of 1 contiguous non-health care occupancy barriers observed was constructed to a two-hour fire resistance rating (first floor nursing home/adult day care). Specifically, the contiguous non-health care occupancy two-hour fire rated first floor nursing home/adult day care had unsealed penetrations. Findings include: On 1/17/19 at 10:15 AM, the contiguous non-health care occupancy two-hour fire rated first floor nursing home/adult day care barrier was observed and included: - the wall over the fire rated double doors had unapproved spray foam and unsealed data wire penetrations; and - one of the separation walls had a 6-inch circular cut-out and an unsealed 5-inch duct was passing through it. During an interview on 1/17/19 at 11:27 AM, the Maintenance Director stated there was no two-hour fire barrier separating the nursing home and the adult day care when the building was originally built, and he was not aware that a two-hour fire barrier was required to separate the occupancies. 2012 NFPA 101: 19.1.3.4.1 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedMarch 7, 2019

PLAN OF CORRECTION
ST. LUKE HEALTH SERVICES
SURVEY EXIT DATE: 1/17/2019

K132 - NFPA 101 Multiple Occupancies - Contiguous Non-Health
Preparation and/or execution of this plan do not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility?s credible allegation of compliance.
1. Corrective action(s) will be / have been accomplished for those residents found to be affected by the deficient practice:
Wall Over Fire Rated Double Doors: The wall over the fire rated double doors will be sealed properly with fire putty/fire caulk/fire proof material to maintain the fire rated assembly. Date Completed: 3/18/2019
One of Separation Walls: The separation wall with the six in circular cut-out and an unsealed 5-inch duct will be sealed properly with fire putty/fire caulk/fire proof material to maintain the fire rated assembly. Date Completed: 3/18/2019
2. Identification of other residents having the potential to be affected by the same deficient practice and corrective action taken:
All other fire wall construction areas and all openings/penetrations are in the process of being inspected by the maintenance department and all openings/penetrations found will be sealed with fire putty/fire caulk/fire proof material to maintain the fire rated assembly. Completion Date: 3/18/2019 and ongoing
3. Measures put in place to ensure that the deficient practice does not recur:
An identification system for firestop systems will be used to label around all fire wall partitions so that it distinguishes rating and to protect all openings and penetrations. Responsible person: Building Engineer /Designee. Completion Date: 3/18/2019 and ongoing

All maintenance staff will be in-serviced by the Building Engineer in regards to the firestop system and the proper steps that must be taken to reseal the penetration when a fire barrier wall is penetrated. Completion Date: 3/8/2019 and ongoing.

4. How the Corrective Actions will be monitored by to ensure the practice will not recur:
A QA monitor will be implemented to ensure fire barrier walls between Adult Day Health Care and the Nursing Home are properly sealed from any openings or penetrations. The audit will be done monthly for three months, then quarterly for six months by Building Engineer/Designee with further frequency of monitoring to be determined by the QA committee. Completion Date: 3/18/2019 and ongoing.
5. Date for Correction: 3/18/2019 and ongoing
6. Person Responsible for Correction: Building Engineer / Designee

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: January 17, 2019
Corrected date: March 18, 2019

Citation Details

Based on observation and interview during the Life Safety Code survey, the facility's building was not protected throughout by an approved automatic sprinkler system for 1 isolated area (main kitchen) in accordance with National Fire Protection Association (NFPA) 13 - Standard for Installation of Sprinkler Systems section 8.3.3.2 which states Where quick response sprinklers are installed, all sprinklers within a compartment shall be quick response unless otherwise permitted in 8.3.3.3. Specifically, the main kitchen contained both quick response and standard response sprinkler heads. Findings include: On 1/15/18 at 10:18 AM, a surveyor in the main kitchen observed 17 standard response heads and 2 quick response heads. During an interview on 1/16/19 at 3:13 PM, the Maintenance Director stated during a 1993 renovation of the kitchen a wall was removed when an addition was added to the building. The existing kitchen contained all standard sprinkler heads, and the new section had quick response sprinkler heads. 2012 NFPA 101: 19.3.5.1, 9.7.1.1 2010 NFPA 13: 8.3.3.2 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedMarch 7, 2019

PLAN OF CORRECTION
ST. LUKE HEALTH SERVICES
SURVEY EXIT DATE: 1/17/2019
K351 - NFPA 101 Sprinkler System - Installation
Preparation and/or execution of this plan do not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility?s credible allegation of compliance.
1. Corrective action(s) will be / have been accomplished for those residents found to be affected by the deficient practice:
Kitchen: All standard sprinklers will be replaced with quick response heads. Date Completed: 3/18/2019
2. Identification of other residents having the potential to be affected by the same deficient practice and corrective action taken:
The Building Engineer/Designee will complete a full building inspection to ensure all areas of the facility are protected by an approved / appropriate automatic sprinkler system (heads) in accordance with NFPA 13. Date Completed: 3/18/2019 and ongoing
3. Measures put in place to ensure that the deficient practice does not recur:
The Building Engineer/Designee will complete quarterly inspections of the sprinkler heads to ensure all areas of the facility have the appropriate / approved automatic system (heads) in accordance with NFPA 13. Date Completed: 3/18/2019 and ongoing
4. How the Corrective Actions will be monitored by to ensure the practice will not recur:
A QA monitor will be implemented to ensure all areas of the facility are protected by any approved / appropriate automatic sprinkler system (head) in accordance with NFPA 13. The audit will be done monthly for three months, then quarterly for six months by Building Engineer/Designee with further frequency of monitoring to be determined by the QA committee. Completion Date: 3/18/2019 and ongoing
5. Date for Correction: 3/18/2019 and ongoing
6. Person Responsible for Correction: Building Engineer / Designee

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: January 17, 2019
Corrected date: March 18, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the Life Safety Code survey, the facility did not ensure the building's automatic sprinkler system was tested in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Specifically, the dry sprinkler heads within the facility were not maintained as required. Findings include: On 1/15/19 at 10:05 AM, a surveyor in the kitchen observed the following: - the walk-in cooler had a dry sprinkler head dated 1992; and - the walk-in freezer had a dry sprinkler head dated 1992. During an interview on 1/16/19 at 3:13 PM, the Maintenance Director stated he was not aware the dry sprinkler heads located in the walk-in cooler and walk-in freezer were required to be tested /replaced every [AGE] years. He could not find any evidence the above-mentioned sprinkler heads had been tested . 2012 NFPA 101: 19.3.5.1, 9.7.5 2011 NFPA 25, 5.1.1 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedMarch 7, 2019

PLAN OF CORRECTION
ST. LUKE HEALTH SERVICES
SURVEY EXIT DATE: 1/17/2019
K353 - NFPA 101 Sprinkler System - Maintenance and Testing
Preparation and/or execution of this plan do not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility?s credible allegation of compliance.

1. Corrective action(s) will be / have been accomplished for those residents found to be affected by the deficient practice:
Walk in Cooler: The dry sprinkler head in the walk in cooler will be replaced with a new dry sprinkler head. Completion Date: 3/18/2019
Walk in Freezer: The dry sprinkler head in the walk in freezer will be replaced with a new dry sprinkler head. Completion Date: 3/18/2019
2. Identification of other residents having the potential to be affected by the same deficient practice and corrective action taken:
The Building Engineer/Designee will complete a full building inspection to ensure all dry sprinkler heads are identified and inspected according to NFPA25. Dry sprinkler heads will be replaced if needed. Records of the system inspection will be maintained according to NFPA25 guidelines. Date Completed: 3/18/2019 and ongoing
3. Measures put in place to ensure that the deficient practice does not recur:
The Building Engineer/Designee will complete quarterly inspections of the dry sprinkler heads to ensure they have been tested / inspected in accordance with NFPA 25. Records of the system inspection will be maintained according to NFPA25 guidelines. Date Completed: 3/18/2019 and ongoing

4. How the Corrective Actions will be monitored by to ensure the practice will not recur:
A QA monitor will be implemented to ensure dry sprinkler heads are tested / inspected as well the records of the inspection are in accordance with NFPA 25. The audit will be done monthly for three months, then quarterly for six months by Building Engineer / Designee with further frequency of monitoring to be determined by the QA committee. Date Completed: 3/18/2019 and ongoing
5. Date for Correction: 3/18/2019 and ongoing
6. Person Responsible for Correction: Building Engineer / Designee