Mosholu Parkway Nursing & Rehabilitation Center
March 7, 2018 Certification/complaint Survey

Standard Life Safety Code Citations

K307 NFPA 101:COOKING FACILITIES

REGULATION: Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 16, 2018
Corrected date: April 16, 2018

Citation Details

Based on observation and staff interview, it was determined that the facility did not ensure that the automatic extinguishing system for the cooking equipment was inspected monthly. This was observed in the kitchen of the facility. The finding is: On (MONTH) 15 (YEAR), at approximately 12:10 pm during the recertification survey, the kitchen Ansul pull station was inspected and it was observed that the monthly inspection tag was not filled out as evidenced by the absence of signatures. In an interview with the Maintenance Staff immediately after the finding on the same day, he stated that the company does the necessary inspection but will let them know about the need for monthly inspections. 2012 NFPA 101 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedApril 4, 2018

I. Corrective action accomplished for areas identified in the survey:
The monthly visual inspection of the Ansul pull station was added to the maintenance check of fire safety equipment and signed off for accordingly. This is in addition to the 2x annual inspections done by the service provider.
II. Identification of other potentially affected areas:
All other fire safety equipment tags were reviewed and found to have the appropriate sign offs.
III. Measure in place or systemic changes made to ensure the same practice does not recur:
The monthly inspection audit which is completed by Maintenance will be reviewed by the Director of Building Services who will also do additional spot checks to assure compliance.
IV. Corrective action will be monitored as follows:
Audit findings will be reported to the QA Committee for review quarterly.
Responsible Party: Director of Building Services

K307 NFPA 101:MEANS OF EGRESS - GENERAL

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 16, 2018
Corrected date: April 30, 2018

Citation Details

2012 NFPA 101: 19.2.1 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. Based on observation and staff interview, it was determined that the facility did not ensure that exit discharge to the outside from the facility was maintained free of obstructions as evidenced by cracks on the concrete floor and water drippage. This was noted for the main egress ramp to the outside of the facility. The Finding is: On (MONTH) 15 (YEAR) and (MONTH) 16 (YEAR), during the life safety code recertification survey of the facility, the main egress ramp to the outside of the facility was observed with cracks in the concrete floor. Also, water drippage was observed directly on the path from the above canopy. These concerns can create a tripping/slipping hazard in the event of an emergency situation. In an interview with the Maintenance Director on (MONTH) 16 (YEAR), at approximately 11:30 a.m, he stated that these will be corrected. 2012 NFPA 101 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedApril 4, 2018

The following plan of correction is submitted in accordance with the applicable law and regulation for continued Medicare/Medicaid certification and does not constitute an admission of fault on the part of the facility.
I. Corrective action accomplished for areas identified in the survey:
Cracks in the concrete floor are scheduled to be repaired.
The main egress ramp will be inspected daily for drippage and corrected for any water present using a broom to dissipate water on the concrete and a squeegee to dry the canopy as needed.
II. Identification of other potentially affected areas:
Other egresses were inspected and found to be without need of repair or presence of water drippage.
III. Measure in place or systemic changes made to ensure the same practice does not recur:
All emergency egresses will be visually inspected daily to assure that they are free of obstructions.
Concrete will be inspected monthly to assure it is in proper repair.
Repairs will be made as needed.
IV. Corrective action will be monitored as follows:
Results of daily/monthly visual inspections and corrective actions will be reported to the Director of Building Services and reported quarterly to the QA Safety committee for review.
Responsible Person: Director of Building Services