K 000 INITIAL COMMENTS K 000 KOOO LIFE SAFETY CODE 101:2000
The facility is not in substantial compliance with the Minimum Life Safety Code requirements as surveyed under CMS-2786R.
K 050 SS=C
NFPA 101 LIFE SAFETY CODE STANDARD Fire drills include the transmission of a fire alarm signal and simulation of emergency fire
conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM a coded announcement may be used instead of audible alarms.
18.7.1.2, 19.7.1.2
This STANDARD is not met as evidenced by:
K 050 4/7/16
Based on surveyor's review of facility records on 3/1/16, it was determined that the facility failed to ensure that fire drills were conducted at
unexpected times as evidenced by the following: A review of the facility's fire drill reports for the last 4 quarters revealed that 3rd. shift fire drills were conducted at varied times. Fire drills were conducted between 11:00 p.m. and 11:45 p.m. as indicated on fire drill reports dated 3/20/16 (11:45 p.m.), 12/31/15 (11:45 p.m.), 8/31/15 (11:00 p.m.) and 6/29/15 (11:00 p.m.).
NJAC 8:39-31.6b
Fire drills will be conducted at unexpected times under varying conditions
Any resident has the potential to be affected
The Administrator will in- service Maintenance Director/ Designee tol conduct fire drills at unexpected times under varying conditions
Administrator/Maintenance
Director/Designee will audit fire drills monthly x3.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
04/01/2016 Electronically Signed
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
A. BUILDING 02
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY COMPLETED PRINTED: 08/10/2017 FORM APPROVED (X2) MULTIPLE CONSTRUCTION B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
315259 03/04/2016
STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER
1180 ROUTE 22 WEST MANOR CARE MOUNTAINSIDE
MOUNTAINSIDE, NJ 07092
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY) (X5) COMPLETION DATE ID PREFIX TAG (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)
K 050 Continued From page 1 K 050
Results of the audits will be forwarded monthly to the Quality Assessment and Assurance Committee for review and action as appropriate.
The Quality Assessment and Assurance Committee will determine the need for further or continued action.
K 052 SS=C
NFPA 101 LIFE SAFETY CODE STANDARD A fire alarm system required for life safety shall be, tested, and maintained in accordance with NFPA 70 National Electric Code and NFPA 72 National Fire Alarm Code and records kept readily available. The system shall have an approved maintenance and testing program complying with applicable requirement of NFPA 70 and 72. 9.6.1.4, 9.6.1.7,
This STANDARD is not met as evidenced by:
K 052 4/7/16
Based on surveyor's interview and review of facility records on 3/1/16, it was determined that the facility failed to ensure that their fire alarm system was tested semiannually (6-month intervals) as evidenced by the following: A review of the facility's fire alarm system
inspection reports for period 3/15 to 3/16 revealed that the system was inspected only once as indicated by a report dated 12/28/15. The previous inspection of the fire alarm system was done on 1/20/15 according to a report provided by the facility. The facility was due for an inspection no later than 6/20/15. The facility was unable to provide a fire alarm system inspection report for this date. The facility's Administrator revealed in an interview on 3/2/16 at approximately 11:30 a.m. that the facility's fire alarm system was only inspected once within the last 12 months. NJAC 8:39-31.2e
Fire Alarm System has been scheduled for June 2016 to meet requirement semiannually (6 month intervals
Anyone in the facility has the potential to be affected.
Administrator/Maintenance Director will schedule Fire Alarm System inspections and have scheduled standing semi-annual June 2016 and December 2016 going forward and have scheduled standing semi-annual inspections.
Results of the inspections June 2016 and December 2016 will be forwarded to the Quality Assessment and Assurance Committee for review and action as appropriate.
K 052 Continued From page 2 K 052
The Quality Assessment and Assurance Committee will determine the need for further or continued action.
K 062 SS=E
NFPA 101 LIFE SAFETY CODE STANDARD Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested
periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5
This STANDARD is not met as evidenced by:
K 062 4/7/16
Based on observation in the presence of the facility's Maintenance Director on 3/1/16 and 3/2/16, it was determined that the facility failed to maintain their automatic sprinkler system in safe operating condition as evidence by the following: A tour of the building revealed that automatic sprinkler heads were not free of obstructions. On 3/1/16 at 10:20 a.m., the surveyor observed a pile of personal clothing stored directly under a ceiling mounted sprinkler head in the wardrobe closet in resident room #209. The top of the clothing pile was touching the sprinkler head's spray deflector, thus obstructing its coverage and discharge pattern. On 3/2/16 at 1:20 p.m., the surveyor observed that the automatic sprinkler head in the kitchen's walk-in freezer was covered with an accumulation of dust. Also, the sprinkler heads glass tube was covered with a rust-like substance. The accumulated dust and rust-like substance could prevent the sprinkler head from quick and prompt activation when needed. NJAC 8:39-31.2(e)
The obstructed sprinkler system in room#209 has been corrected. The automatic sprinkler head in the kitchen’s walk-in freezer was replaced. Anyone in the facility has the potential to be affected.
Administrator/Maintenance Director will complete random checks of facility for sprinkler heads so that are free from obstruction and are maintained. Administrator/Maintenance
Director/Designee will randomly check sprinklers for obstructions and are maintained. Weekly x4 and monthly x3. Results of the audits will be forwarded monthly to the Quality Assessment and Assurance Committee for review and action as appropriate.
The Quality Assessment and Assurance Committee will determine the need for
A. BUILDING 02
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY COMPLETED PRINTED: 08/10/2017 FORM APPROVED (X2) MULTIPLE CONSTRUCTION B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
315259 03/04/2016
STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER
1180 ROUTE 22 WEST MANOR CARE MOUNTAINSIDE
MOUNTAINSIDE, NJ 07092
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY) (X5) COMPLETION DATE ID PREFIX TAG (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)
K 062 Continued From page 3 K 062
further or continued action. K 147
SS=C
NFPA 101 LIFE SAFETY CODE STANDARD Electrical wiring and equipment shall be in accordance with National Electrical Code. 9-1.2 (NFPA 99) 18.9.1, 19.9.1
This STANDARD is not met as evidenced by:
K 147 4/7/16
Based on review of facility records on 3/1/16, it was determined that the facility failed to ensure that the building's electrical system was inspected annually by a licensed electrician as evidenced by the following:
A review of the electrical system inspection reports provided by the facility revealed that the system was last inspected in 2014 as indicated on a report dated 3/24/14. The facility did not have their electrical system inspected in 2015 and was unable to provide any additional information.
NJAC 8:39-31.6b
Electrical system was inspected on February 24rd 2016
Anyone in the facility has the potential to be affected.
Administrator/Maintenance Director will have electrical inspection annually by licensed electrician.
The Administrator /Maintenance Director schedule electrical inspection 3 months prior to annual requirement.
Copy of electrical inspection will be submitted to Quality Assessment and Assurance Committee review and action as appropriate.
The Quality Assessment and Assurance Committee will determine the need for further or continued action.
provision number and the identification prefix code previously shown on the CMS-2567 (prefix codes shown to the left of each requirement on the survey report form).
Y4 ITEM Y5 DATE Y4 ITEM Y5 DATE DATE Y5 ITEM Y4 ID Prefix Correction
Reg. # NFPA 101 Completed
LSC K0050 04/07/2016
ID Prefix Correction
Reg. # NFPA 101 Completed
LSC K0052 04/07/2016
ID Prefix Correction
Reg. # NFPA 101 Completed
LSC K0062 04/07/2016
ID Prefix Correction
Reg. # NFPA 101 Completed
LSC K0147 04/07/2016 ID Prefix Correction Reg. # Completed LSC ID Prefix Correction Reg. # Completed LSC ID Prefix Correction Reg. # Completed LSC ID Prefix Correction Reg. # Completed LSC ID Prefix Correction Reg. # Completed LSC ID Prefix Correction Reg. # Completed LSC ID Prefix Correction Reg. # Completed LSC ID Prefix Correction Reg. # Completed LSC ID Prefix Correction Reg. # Completed LSC ID Prefix Correction Reg. # Completed LSC ID Prefix Correction Reg. # Completed LSC REVIEWED BY STATE AGENCY REVIEWED BY CMS RO REVIEWED BY (INITIALS) REVIEWED BY (INITIALS) DATE
DATE SIGNATURE OF SURVEYOR
TITLE DATE
DATE
FOLLOWUP TO SURVEY COMPLETED ON CHECK FOR ANY UNCORRECTED DEFICIENCIES. WAS A SUMMARY OF
UNCORRECTED DEFICIENCIES (CMS-2567) SENT TO THE FACILITY? YES NO 3/4/2016
