Sapphire Nursing at Meadow Hill
August 9, 2017 Certification Survey

Standard Health Citations

FF10 483.25(d)(1)(2)(n)(1)-(3):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: (d) Accidents. The facility must ensure that - (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed?s dimensions are appropriate for the resident?s size and weight.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 9, 2017
Corrected date: September 28, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during a recertification survey, the facility did not ensure that a safety devise was provided in accordance with the written care plan to prevent further injuries secondary to falls for 1 of 2 residents (#211) reviewed for accidents. Specifically, the facility did not provide a safety device (floor mat) in a timely manner to prevent potential for further injury. The finding is: Resident #211 has [DIAGNOSES REDACTED]. A review of nursing notes revealed that this resident fell out of bed on 3/31/17 with no injury. The Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that this resident has severely impaired cognition, totally dependent in all spheres of activities of daily living, and had a fall since the last admission or the prior assessment with no injuries. The nursing progress notes revealed the resident had further falls from the bed on 7/15/17, 7/17/17 and 8/5/17. In the 7/15/17 fall, the resident slid out of bed to the floor with his legs remaining on the bed and sustained a skin tear to the elbow. The falls of 7/17/17 and 8/5/17 did not result in any injury. The care plan for falls indicated that on 8/5/17, the plan to prevent further falls was to place a floor mat at the side of the resident's bed. The resident's room was observed on 8/9/17 at 10:30 AM and revealed there was no floor mat placed at the side of the bed or was available at any location in the resident's room. The unit nurse manager was interviewed on 8/9/17 at 11:00 AM as to why there was no floor mat in the resident's room. The Nurse Manager stated that she ordered the floor mat four days earlier from a sister facility but it was not yet delivered. Following surveyor's inquiry, the nurse manager immediately obtained a floor mat and placed it at the side of the resident's bed. 415.12(h)(l)

Plan of Correction: ApprovedAugust 25, 2017

1.The safety device (floor mats) was provided to resident # 211 per care plan intervention on 8/9/2017, to prevent further injury secondary to falls.
2.All residents who have experienced an accident, from 7/1/17 to present, will have their care plan reviewed to ensure any safety device which has been determined as a necessary intervention is in place. Confirmation of the safety device will be made by direct observation by the ADON, and will be noted on the fall audit log.
3.Education will be provided to the unit managers and RN Supervisors regarding the implementation and interventions for accidents to prevent potential for further injury.
4.Accidents/falls will be audited on a weekly basis during the falls committee meeting for initiation and interventions of care plans to ensure the intervention has been implemented. Confirmation of the safety device will be made by direct observation by the ADON, and noted on the fall audit log. Results will be reported to the QAPI committee for further recommendation.
Responsible Person: DON/Designee

FF10 483.70(i)(1)(5):RES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE

REGULATION: (i) Medical records. (1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized (5) The medical record must contain- (i) Sufficient information to identify the resident; (ii) A record of the resident?s assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician?s, nurse?s, and other licensed professional?s progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 9, 2017
Corrected date: September 28, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a recertification survey, the facility did not ensure that the clinical record for each resident, when indicated, reflected care provided and the resident's response to the care. This was evident for 1 of 5 residents (#164) reviewed for unnecessary medications. Specifically, information related to indication for use and the resident's response to the administration of a pain medication to be used as needed were not consistently documented in the clinical record. The findings are: Resident#164 has [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) dated 4/11/17 and 6/29/17 revealed that the resident has moderately impaired cognition. A review of the resident's physician's orders [REDACTED]. The care plan for pain dated 7/7/17 revealed that the goal for the resident was to maintain adequate level of comfort as evidenced by no signs and symptoms of unrelieved pain or distress. The interventions to achieve this goal included verbalizing satisfaction with level of comfort or observation of satisfaction and to report or staff to identify and document relief of pain within one hour of receiving pain medications. The Medication Administration Record [REDACTED]. There was no documented evidence that the resident's pain level was assessed prior to administration for all these dates and no response to the medication noted for all dates, excluding 8/4. The Licensed Practical Nurse who administered the medication was interviewed in the afternoon of 8/7/17. She stated that she did assess the intensity of the resident's pain and did follow-up to determine her response to the medication but did not document the information in the record. 415.22 (a)(1)(2)

Plan of Correction: ApprovedAugust 23, 2017

1. The clinical record for resident #164 was reviewed comprehensively to ensure the indication for use,response to pain medication, is appropriate.
2. The clinical record for all residents receiving prn pain medication will be reviewed to ensure the indication for use, resident pain level is assessed, and resident response is consistently documented.
3. Education for all licensed nurses will be provided to assure documentation in the medical record is consistently noted for the use and response to the administration of PRN meds, specifically pain medications.
4. Weekly audits will be conducted x 2 months to ensure proper documentation is provided . Results will be reported to the QAPI committee for further recommendations.
Responsible person: DON/designee

FF10 483.10(c)(2)(i-ii,iv,v)(3),483.21(b)(2):RIGHT TO PARTICIPATE PLANNING CARE-REVISE CP

REGULATION: 483.10 (c)(2) The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to: (i) The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care. (ii) The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. (iv) The right to receive the services and/or items included in the plan of care. (v) The right to see the care plan, including the right to sign after significant changes to the plan of care. (c)(3) The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must-- (i) Facilitate the inclusion of the resident and/or resident representative. (ii) Include an assessment of the resident?s strengths and needs. (iii) Incorporate the resident?s personal and cultural preferences in developing goals of care. 483.21 (b) Comprehensive Care Plans (2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident?s medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident?s care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 9, 2017
Corrected date: September 28, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a recertification survey, the facility did not revise the care plan for 1 of 5 residents (#164) reviewed for unnecessary medication regarding the use of an antianxiety medication that was used to address anxiety and [MEDICAL CONDITION]. The findings are: Resident#164 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS; a resident assessment tool) dated 4/11/17 and 6/29/17 revealed that the resident has moderately impaired cognition and has difficulty with sleeping. The 4/11/17 MDS noted that the resident was on antidepressant and hypnotic medications. The 6/29/17 MDS did not indicate the use of a hypnotic. The nurses' notes documented on 7/8/17 that the resident was restless throughout the night, complained of not being able to sleep, and pacing up and down the unit in her wheelchair. This note stated that she was moderately confused. The physician documented in his progress notes of 7/10/17 that he was asked to evaluate the resident due to complaint of [MEDICAL CONDITION], which was affecting the resident's quality of life. The plan by the physician was to start [MEDICATION NAME] 1 mg as needed. A review of the Medication Administration Record [REDACTED]. The Certified Nurse Aide (CNA) assigned to the resident on the evening shift was interviewed on 8/8/17 at about 3:45 PM and was asked what time the resident likes to go to bed. She stated between 9:00 PM and 9:30 PM. The unit Registered Nurse (RN) manager was interviewed on 8/8/17 at 3:55 PM and was asked why the medication was being administered at the times noted, between 9:00 PM and 9:30 PM, when the resident had not yet demonstrated that she was having difficulty going to sleep. The RN manager stated that this was because the resident is usually anxious at that time and the medication was administered to calm her down so that she could go to sleep. A review of the resident's plan of care to address the use of psychoactive medications (or any other aspect of the resident's care plan to include cognitive impairment and behavior) was not revised to address the use of [MEDICATION NAME] ordered on [DATE] for [MEDICAL CONDITION] and to address anxiety. This was confirmed with the Unit Manager at the time of the above mentioned interview. 415.11(c)(2)(i-iii)

Plan of Correction: ApprovedAugust 23, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. The care plan for resident #164 was revised on 8/7/17 to address the use of a psychoactive medication necessary to address her [MEDICAL CONDITION] and anxiety.
2. The care plans for all residents receiving psychoactive medications will be reviewed to ensure the care plan has been initiated or revised addressing the need for each medication, to include appropriate goals and interventions.
3.Education will be provided to the Unit Managers and MDS coordinators to continue to review and revise the care plans of those residents receiving psychoactive medications .
4.An audit will be conducted monthly x 3 months to monitor for review and revision of care plans addressing the use of psychoactive medications. The results will be reported to QAPI committee for further recommendations
Responsible person: DON/Designee
9/28/2017

FF10 483.21(b)(3)(ii):SERVICES BY QUALIFIED PERSONS/PER CARE PLAN

REGULATION: (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (ii) Be provided by qualified persons in accordance with each resident's written plan of care.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 9, 2017
Corrected date: September 28, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during a recertification survey, the facility did not ensure that care and services were provided in accordance with the care plan based on comprehensive assessment for 1 of 2 residents (#211) reviewed for accidents. Specifically, the facility did not provide a safety device (floor mat) in a timely manner to prevent potential for further injury. The finding is: Resident #211 has [DIAGNOSES REDACTED]. A review of nursing notes revealed that this resident fell out of bed on 3/31/17 with no injury. The Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that this resident has severely impaired cognition, totally dependent in all spheres of activities of daily living, and had a fall since the last admission or the prior assessment with no injuries. The nursing progress notes revealed the resident had further falls from the bed on 7/15/17, 7/17/17 and 8/5/17. In the 7/15/17 fall, the resident slid out of bed to the floor with his legs remaining on the bed and sustained a skin tear to the elbow. The falls of 7/17/17 and 8/5/17 did not result in any injury. The care plan for falls indicated that on 8/5/17, the plan to prevent further falls was to place a floor mat at the side of the resident's bed. The resident's room was observed on 8/9/17 at 10:30 AM and revealed there was no floor mat placed at the side of the bed or was available at any location in the resident's room. The unit nurse manager was interviewed on 8/9/17 at 11:00 AM as to why there was no floor mat in the resident's room. The Nurse Manager stated that she ordered the floor mat four days earlier from a sister facility but it was not yet delivered. Following surveyor's inquiry, the Nurse Manager immediately obtained a floor mat and placed it at the side of the resident's bed. 415.11(c)(3)(ii)

Plan of Correction: ApprovedAugust 25, 2017

1.The safety device (floor mats) was provided to resident #211 per care plan intervention on 8/9/2017.
2.All residents who have experienced a fall from 7/1/17 to present, will have their care plan reviewed to ensure any safety device which has been determined as a necessary intervention,is in place. The ADON will determine compliance via direct observation, and note findings on the fall audit log.
3.Education will be provided to the Unit Managers and RN Supervisors regarding the implementation and interventions for falls to prevent potential for further injury.
4.All falls will be audited on a weekly basis during the falls committee meeting for initiation and interventions of careplans to ensure the intervention has been implemented. The ADON will determine compliance via direct observation, noting findings on the fall audit log. Results will be reported to the QAPI committee for further recommendation.
Responsible person: DON/Designee
9/28/2017

Standard Life Safety Code Citations

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 9, 2017
Corrected date: October 16, 2017

Citation Details

2012 NFPA 99 Section 6.4.1.1.17 Alarm Annunciator. A remote annunciator, that is storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.) The annunciator shall be hard wired to indicate alarm conditions of the emergency or auxiliary power source as follows: (a) Individual visual signals shall indicate the following: 1. When the emergency or auxiliary power source is operating to supply power to load 2. When the battery charger is malfunctioning (b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following: 1. Low lubricating oil pressure 2. Low water temperature 3. Excessive water temperature 4. Low fuel 5. Overcrank (failed to start) 6. Overspeed Based on observation and staff interview during the recertification survey, an emergency generator remote annunciator panel indicating individual visual signals for varying alarm conditions was not provided in accordance with NFPA 99. The findings are: During the recertification survey conducted on 8/4/17 at approximately 2:25 PM, it was noted that the facility's emergency generator, which is located in the basement of the building, was not provided with a remote annunciator panel in a location separate from the generator that can be readily observed by personnel at a regular work station. In an Interview at the time of the finding, the Director of Environmental Services could not provide an explanation as to why a remote annunciator panel was not provided in the facility. 2012 NFPA 99: 6.4.1.1.17 10 NYCRR 711.2(a)(1)

Plan of Correction: ApprovedAugust 31, 2017

1. A vendor will be contracted to install an alarm annunciator panel to indicate alarm conditions and malfunctions of emergency power source for EES. The panel will be located in a 24 hour staffed area (nurses? station). The wiring and battery backup will be compliant with the standards for EES.
2. Facility will monitor panel for trouble indicators daily to address issues as needed.
3. Maintenance and nursing staff will be educated on the panels function and how to report issues.
4. Director of Environmental Services/designee will review the findings and report at the monthly QAPI meetings x 3 months.
Responsible Person: Director of Environmental Services/designee

K307 NFPA 101:ILLUMINATION OF MEANS OF EGRESS

REGULATION: Illumination of Means of Egress Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention. 18.2.8, 19.2.8

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 9, 2017
Corrected date: October 16, 2017

Citation Details

2012 LSC 101: 7.8 Illumination of Means of Egress 7.8.1.1 Illumination of means of egress shall be provided in accordance with Section 7.8 for every building and structure where required in Chapters 11 through 42. For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way. 7.8.1.2 Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use, unless otherwise provided. 7.8.1.4* Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2.2 lux) in any designated area. 7.9 Emergency Lighting 7.9.2.3* The emergency lighting system shall be arranged to provide required illumination automatically in the event of any interruption of normal lighting due to the following: (1) Failure of a public utility or other outside electrical power supply (2) Openings of a circuit breaker or fuse (3) Manual act(s), including accidental openings of a switch controlling normal lighting facilities. Based on observation and interview, the facility did not ensure the following; 1) The illumination of the means of egress in corridors was installed and maintained in accordance with 7.8. and 7.9. This was evidenced by wall-mounted switches located in the corridors on the first floor and in the basement, which, when turned off, would turn all lighting off in these corridors. This would not ensure that required and sufficient lighting would be continuously provided and capable of automatic operation without manual intervention; and 2) The failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2.2 lux) in any designated area. The findings are: During the life safety tour conducted on 8/3/17 and 8/4/17 between 10:00 AM and 3:00 PM, the following issues with illumination were noted: 1) Wall mounted switches on 2 of 2 resident floors (1st and basement), when turned to the off position, turned all of the lights off in the corridors. This would not ensure that required and sufficient lighting would be continuously provided and capable of automatic operation without manual intervention. 2) On 5/4/17 at approximately 10:30 AM, a tour of the grounds and exterior of the building revealed single bulb light fixtures installed at 6 of 6 emergency exits in the facility. This would not ensure that the failure of any single lighting unit would not result in an illumination level of less than 0.2 ft-candle (2.2 lux) at these exits. In an interview at the time of the findings, the Director of Environmental Services stated that the wall mounted switches will be changed to ensure that the lighting in the corridors is continuously provided. She further stated that the single bulb fixtures at the exit discharges will also be changed. 2012 NFPA 101: 7.8.1.1, 7.8.1.2, 7.8.1.4*, 7.9.2.3* 10 NYCRR 711.2(a)(1)

Plan of Correction: ApprovedAugust 31, 2017

I.
1. The identified areas that were not in compliance with regard to providing illumination in the egress corridors will be rewired so that sufficient (one continuous row) lighting will be continuously provided in a manner capable of automatic operation without manual intervention. The lighting will be tied in to EES (generator) and on switches requiring a key so that repairs and maintenance can be conducted as part of the effort to maintain adequate lighting in the corridors. Bids are being collected from service providers.
2. To ensure compliance and safety throughout the facility all egress passages will be identified and the switches rewired and tied into EES.
3. In order to ensure compliance throughout the facility staff will be educated on: A) the definition of egress corridors and the need for adequate lighting there and: B) Reporting issues causing disruption to the illumination so that they can be immediately addressed.
4. The Director of Environmental services or designee will conduct routine rounds during monthly load runs of the generator to ensure function. The results will be reported at the monthly QAPI meeting.
II.
1. The single bulb fixtures at the exterior of the building, emergency exits to public areas, will be replaced with fixtures having two or more bulbs. This will ensure illumination of not less than 0.2ft- candle in any designated area. The lighting will be tied into EES. Parts will be ordered and installation completed by 9/30/17.
2. The maintenance department will assess all vestibules and exterior exit lights to ensure they are in compliance with the standard that exists.
3. The functioning of the lights will be assessed during monthly load tests.
4. The Director of Environmental Services/designee will conduct regularly scheduled audit of the exterior exit lighting to ensure continued function and light output and the findings will be reported at the monthly QAPI meeting.

Responsible Person: Director of Environmental Services/designee

ZT1N 415.29:PHYSICAL ENVIRONMENT

REGULATION: N/A

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 9, 2017
Corrected date: October 16, 2017

Citation Details

415.29 Physical environment. The nursing home shall be designed, constructed, equipped and maintained to provide a safe, healthy, functional, sanitary and comfortable environment for residents, personnel, and the public. (h) Ventilating, heating, and air conditioning systems. Such systems shall: (1) be maintained in good repair and shall be operated in a manner which will not allow for the spread of infection and provide for resident health and comfort; and (2) be maintained and operated in such manner that air shall not be circulated from resident isolation rooms, laboratories in which work is done in pathology, virology or bacteriology, autopsy rooms, kitchen and dishwashing areas, toilet and bath rooms, janitors' closets and soiled utility rooms or soiled linen rooms, to other parts of the facility. 713-1.18 Mechanical requirements. (d) Heating and ventilating systems. (2) Ventilation system details. All air-supply and air-exhaust systems shall be mechanically operated. All fans serving exhaust systems shall be located at the discharge end of the system. The ventilation rates shown in Table 8 shall be considered as minimum acceptable rates and shall not be construed as precluding the use of higher ventilation rates. (ii) The ventilation systems shall be designed and balanced to provide the pressure relationship as shown in Table 8. Based on observation and interview, the facility did not ensure that the mechanical ventilation system installed in the soiled utility room on 1 of 2 floors (1st floor) was functioning to provide the minimum ventilation rates in compliance with Table 8. The findings are: On 8/4/17 during the life safety tour of at approximately 2:20 PM, the soiled utility room located on the first floor was toured. It was noted that the ceiling exhaust system in the room was tied into the light switch for the room, and the light switch was in the 'off' position at the time of the tour. This condition would not ensure that the required minimum air exchanges were provided in the room. In an interview at the time of the findings, the Director of Environmental Services stated that she will contact the vendor to ensure that the required minimum air exchanges are provided in the soiled utility room. 10 NYCRR 415.29 (h)(1)(2) 10 NYCRR 713-1.18 (d)(2)(ii)

Plan of Correction: ApprovedAugust 31, 2017

1. The air exhaust system in the 1 west soiled utility room will be rewired to operate continually so as to provide the acceptable rate of air exchanges.
2. To ensure safety and compliance, all other areas requiring ventilation were inspected to ensure exhaust system functions continually to provide the acceptable rate of air exchanges.
3. Housekeeping and maintenance staff will be educated on the importance of exhaust systems in maintaining a healthy, sanitary environment and the importance of reporting the absence or malfunction of the exhaust system so issues can be addressed.
4. Director of Environmental Service/designee will audit the exhaust systems to verify that they are present. Any exhaust system failing to meet the required number of air exchanges will be addressed. The results of these audits will be reported at the monthly QAPI meeting.
Responsible person: Director of Environmental Services

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 9, 2017
Corrected date: October 16, 2017

Citation Details

2011 NFPA 25 Chapter 5 Sprinkler Systems. 5.2* Inspection. 5.2.1 Sprinklers. 5.2.1.1* Sprinklers shall be inspected from the floor level annually. 5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendant, or sidewall). Chapter 8 Fire Pumps 8.3* Testing 8.3.1. Frequency 8.3.1.2* Electric- motor driven fire pumps shall be operated monthly. 8.3.2.3 The electric pump shall run a minimum of 10 minutes. 8.3.2.8* The pertinent visual operations or adjustments specified in the following checklists shall be conducted while pump is running: (1) Pump system procedure as follows: (a) Record the system suction and discharge pressure gauge readings (b) Check the pump packing glands for slight discharge (c) Adjust gland nuts if necessary (d) Check for unusual noise or vibration (e) Check packing boxes, bearings, or pump casing for overheating (f) Record the pump starting pressure (2) Electrical system procedures as follows: (a) Observe the time for motor to accelerate to full speed (b) Record the time controller is on first step (for reduced voltage or reduced current starting) (c) Record the time pumps runs after starting (for automatic stop controllers). 13.6 Backflow Prevention Assemblies. 13.6.2 Testing. 13.6.2.1* All backflow preventions installed in fire protection system piping shall be tested annually by conducting a forward flow test of the system at the designed flow rate, including hose stream demand, where hydrants or inside hose stations are located downstream of the backflow preventer. 2010 NFPA 13 Standard for the Installation of Sprinkler Systems 8.8.5.1.1 Sprinklers shall be located so as to minimize obstructions to discharge as defined in 8.8.5.2 and 8.8.5.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard. 8.8.5.3.2 Sprinklers shall be installed under fixed obstructions over 4 ft (1.2 m) wide such as ducts, decks,open grate flooring, cutting tables, and overhead doors. Based on observation and documentation review, the facility did not ensure that the automatic sprinkler system installed in required areas were maintained in accordance with NFPA 25 and NFPA 13, as evidenced by: 1. Documentation of monthly tests of the fire pump and a report for the current year's annual test of the backflow prevention device were not provided; 2. Sprinklers heads were bent, exhibited signs of corrosion (rust and green discoloration) and/or were coated with ice; and 3. Sprinkler heads were obstructed by an HVAC duct in the boiler room. The findings are: During the life safety tour and review of maintenance records conducted on 8/3/17 and 8/4/17 between the hours of 10:00 AM to 2:30 PM, the following issues with the facility's automatic sprinkler system were noted: 1. Documentation of the required monthly tests of the fire pump and the current year's annual test and inspection report for the backflow prevention device were not provided. During the review of routine sprinkler maintenance documentation on 8/3/17 at approximately 10:00 AM, the report of the annual test of the electric motor driven fire pump was provided. However, documentation of the required monthly churn tests for this fire pump was not available. Also, the last annually test and maintenance report provided for the backflow prevention device was dated (MONTH) 5th, (YEAR). A report was not provided for this calendar year (2017). In an interview at the time of the findings, the Director of Environmental Services could not provide an explanation for the missing monthly fire pump reports, and stated that the backflow prevention device was last tested and inspected in (MONTH) (YEAR). 2. On 8/4/17 the following issues with sprinkler heads were noted: - At approximately 10:25 AM, a tour of the kitchen was conducted and revealed that 1 of 4 sprinklers in the kitchen was bent and there was ice accumulation on the sprinkler head in the walk-in freezer. In an interview at the time of the findings, the Kitchen Director stated that the frequent opening and closing of the door to the walk-in freezer may be causing condensation to build up on the sprinkler. - At approximately 11:05 AM, a tour of the laundry room was conducted and it was noted that the sprinklers above the washer and dryer exhibited signs of corrosion. - At approximately 11:15 AM, a tour of the boiler room was conducted and it was noted that the spray pattern of the sprinklers installed in the room may be obstructed by an HVAC duct. Also, there was no sprinkler coverage provided for the facility's emergency generator, which was located adjacent to the HVAC equipment. In an interview at the time, the Director of Environmental Services stated that the sprinklers are checked monthly. 2012 NFPA 101 2011 NFPA 25: 5.2.1.1.1, 5.2.2.2, 8.3.1.2*, 8.3.2.3, 8.3.2.8, 13.6.2.1 2010 NFPA 13: 8.8.5.1.1, 8.8.5.3.2 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedAugust 31, 2017

I.
1. Documentation of monthly fire pump tests will be provided from the previous year to date.
2. Fire pump testing for (MONTH) was completed and documented.
3. A) The fire pump will be tested monthly and; B) The maintenance department will be educated on test parameters, methods for fire pump testing and the need for logging the test accurately.

4. The Director of Environmental Services/designee will conduct monthly audits of the fire pump test log. The results will be reported at the monthly QAPI meeting.
II.
1. The service vendor has been contacted for backflow prevention device testing and documentation.
2. The backflow prevention device will be tested annually along with other fire suppression devices/systems to ensure compliance with the standard throughout the facility.
3. The backflow prevention device testing will be scheduled in sync with fire pump testing to ensure compliance with the standard.
4. The Director of Environmental Services/designee will report the results at the monthly QAPI meeting.
III.
1. The identified areas that were not in compliance with the standard that exists will be replaced or corrected by the service vendor. The remaining sprinkler heads will be inspected by the maintenance department bi monthly for signs of dust, corrosion, discoloration. All sprinkler heads will be brought into compliance.
2. The Maintenance Department completed an inspection of all sprinkler heads to ensure that they are in compliance with the standard that exists.
3. The facility will perform monthly inspections of all sprinkler heads and report issues that are non- compliant with the standard so that they can be addressed. The facility will perform regularly scheduled cleaning of the sprinkler heads bi-monthly so that the facility will have all sprinkler heads inspected and cleaned every two months.
4. The Director of Environmental Services/designee will conduct regularly scheduled audits of the facility to ensure that sprinkler heads are free from dust/fibers, corrosion, discoloration and rust. Additionally, s/he will ensure that all escutcheon plates are present. All negative findings will be addressed immediately.
Responsible Person: Director of Environmental Services/designee