Boro Park Center for Rehabilitation and Healthcare
September 18, 2017 Certification Survey

Standard Health Citations

FF10 483.60(i)(1)-(3):FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY

REGULATION: (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. (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 18, 2017
Corrected date: October 17, 2017

Citation Details

Based on observations and staff interviews during the recertification survey, the facility did not ensure that food was stored and served under sanitary conditions. Specifically, multiple cases of canned food were observed to be expired in the food storage area. Additionally, during the tray line service, several food service employees were without facial hair covering. This was evident during the Kitchen/Food Service Observation. The findings are: During the initial tour of the kitchen on 9/12/17 at at 9:15 am, the following expired food items were observed in the storeroom: Four cases of cut green beans were dated 3/28/16 and two cases were dated 5/14/15. An interview was immediately conducted with the Food Service Supervisor. The Supervisor stated that the dietary staff are responsible for rotating food items every 4 to 6 months. An interview was conducted with the Director of Food Service (FSD) on 9/12/17 at 9:30 am. The FSD stated that the facility can hold the canned items for one to one and a half years. A designated storeroom person is responsible for checking the canned goods. An interview was conducted with the Dietary Aide responsible for checking the storeroom stock on 9/12/17 at 9:45 am. The aide stated that he checks the canned goods every 3 to 6 months, certain food items have shorter shelf lives such as cranberry sauce and items such as mashed potatoes have longer shelf lives. Cut green beans have a longer shelf life and can be held for one year. Beyond one year the worker would open the can to determine the quality. After observation of the expired string beans, the aide stated he would go by the processing date or label date that it was delivered. The Food Storage Policy dated 4/2017 documented: All stock must be rotated with each new ordered received. Rotating stock is essential to assure the freshness and highest quality of all food. Canned goods should be used and rotated within six months. A trayline observation was conducted on 9/14/17 at 11:15 AM. During the observation, several food service workers on the trayline and in the kitchen were observed without facial hair coverings. The FSD was interviewed and stated that the policy and procedure for hair and beard covering is posted throughout the kitchen. Hair on the employees head is covered before entering the kitchen and is to be worn at all times. Workers with a half an inch of facial hair or have a beard, a net is supposed to be worn. The Food Service Supervisor was also interviewed and stated that all food service workers should wear hair covering including the hair on their heads as well as their beards. The policy on Staff Appearance and Hygiene dated 4/2014 documented that regardless of length, hairnet, hat and beard guard is required in all production and service areas. 415.14(h)

Plan of Correction: ApprovedSeptember 28, 2017

1a. When it was determined that multiple cases of canned foods were expired in the food storage area, the cases were discarded immediately to ensure nobody would use them.
1b. The store room was checked as well as all areas of the kitchen that may have canned items to ensure that no other canned items could be expired. None were found.
1c. The food storage policy and procedure was revised to include daily rounds by the FSD as well as the storeroom dietary aide, to determine that no canned goods are expired. Any canned items that have an expiration date will be discarded. A department wide in-service was given to all dietary workers by the FSD explaining this updated policy. The documented in-service as well as sign in sheets were reviewed by the administrator. The audit tool will be reviewed by the administrator for compliance.
1d. On a quarterly basis the FSD will track all canned goods via an audit to determine when they were received and if they have been rotated properly according to our policy. A copy of this audit will be given to the administrator for his review.
2a. When it was determined that several food service workers were observed without facial hair coverings, beard nets were placed on all those workers immediately.
2b. All other dietary workers were checked to see if any facial hair was exposed and if beard nets would be needed. None were found. The FSD also did spot checks to see if hair nets would be needed, but all workers were in compliance.
2c. A department wide in-service on proper hair net usage was conducted by the FSD explaining the department policy. The documented in-service as well as sign in sheets were reviewed by the administrator. The FSD and dietary supervisors will do daily spot checks during each tray line time as well as when any dietary employee is in contact with food, to ensure proper hair covering policy. An audit tool will be developed and reviewed by the FSD to monitor usage. The administrator will review the audit tool for compliance.
2d. On a monthly basis the FSD will review dietary policies and procedures with the dietary employees. As part of these in-services, BPCs hair policy will be reviewed with all staff members. A copy of the in-services and sign in sheets will be reviewed by the administrator.

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: September 18, 2017
Corrected date: November 1, 2017

Citation Details

2012 NFPA 101: 9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service. 2011 NFPA 96: 10.2.6 Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer's instructions, and the following standards where applicable: (1) NFPA 12 (2) NFPA 13 (3) NFPA 17 (4) NFPA 17A 2009 NFPA 17A: 7.2 Owner's Inspection. 2009 NFPA 17A: 7.2.1 On a monthly basis, inspection shall be conducted in accordance with the manufacturer's listed installation and maintenance manual or the owner's manual. 2009 NFPA 17A: 7.2.2 At a minimum, this quick check or inspection shall include verification of the following: (1) The extinguishing system is in its proper location. (2) The manual actuators are unobstructed. (3) The tamper indicators and seals are intact. (4) The maintenance tag or certificate is in place. (5) No obvious physical damage or condition exists that might prevent operation. (6) The pressure gauge(s), if provided, shall be inspected physically or electronically to ensure it is in the operable range. (7) The nozzle blowoff caps, where provided, are intact and undamaged. (8) Neither the protected equipment nor the hazard has not been replaced, modified, or relocated. 2009 NFPA 17A: 7.2.5 At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded. Based on observation, staff interview and documentation review, the facility did not conduct the required monthly inspections of the range hood fire extinguishing system (ANSUL) within the kitchen in the sub-basement. The findings are: On 9/15/17 at approximately 11:09am during the recertification survey, the last documented ANSUL inspection in the kitchen in the sub-basement was completed in (MONTH) (YEAR) as noted by tags on the pull station and containers. There was no documented monthly ANSUL inspections noted since the service date. In an interview on 9/15/17 at approximately 11:09am, the Director of Engineering stated that the visual inspections are done quarterly. 2012 NFPA 101: 9.2.3 2011 NFPA 96: 10.2.6 2009 NFPA 17A: 7.2, 7.2.1, 7.2.2, 7.2.5 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedOctober 30, 2017

1. When it was determined by the state surveyor that the Range(NAME)Fire Extinguishing System (ANSUL) in the kitchen located in the sub-cellar was not inspected monthly under the NFPA 96, standard for violation Control and Fire Protection of Commercial Cooking Operations, an immediate visual inspection or ?quick check? of the ANSUL SYSTEM was conducted and was found to be in working order.
2. All hoods were given a ?quick check? on both the meat and dairy sides and a monthly audit has begun to ensure that the maintenance staff is doing a visual inspection of the hood. A monthly PM was created to coincide with our quarterly inspection and semi-annual inspection. The monthly PM created will follow the 2009 NFPA 17A: 7.2 owner?s inspection which illustrates the necessary requirements.
3. An in-service was given to the maintenance staff on the regulatory requirements pertaining to violation control and fire protection of commercial cooking operations along with NFPA 7.2 owner?s inspection. Staff was also in-serviced on the importance of maintaining the Ansul system. The ?quick check? monthly visual inspection was also part of the in-service to ensure all engineering staff comply.
4. A monthly visual inspection will be conducted by the maintenance staff to ensure the integrity of the ANSUL system is not compromised. This new audit will be part of the engineering monthly QA and this written report will be reviewed by the administrator.
5. Responsible party: Director of maintenance or designee

K307 NFPA 101:GAS EQUIPMENT - CYLINDER AND CONTAINER STORAG

REGULATION: Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING." Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 18, 2017
Corrected date: November 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 99: 11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures: (11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart. 2012 NFPA99: 11.3.2* Storage for nonflammable gases greater than 8.5 m3 (300 ft3), but less than 85 m3 (3000 ft3), at STP shall comply with the requirements in 11.3.2.1 through 11.3.2.3. 11.3.2.1 Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. 11.3.2.2 Oxidizing gases, such as oxygen and [MEDICATION NAME] oxide, shall not be stored with any flammable gas, liquid, or vapor. 11.3.2.3 Oxidizing gases such as oxygen and [MEDICATION NAME] oxide shall be separated from combustibles or materials by one of the following: (1) Minimum distance of 6.1 m (20 ft) (2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems (3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/2 hour Based on observation and staff interview, the facility failed to ensure that oxygen cylinders were properly stored in a cart or container and were not stored within 5 feet of combustibles. This occurred on 2 of 9 floors of the facility. The findings are: On 9/15/2017 and 9/18/2017 between the hours of 9am and 3pm during the recertification survey, the following was observed: At the nursing station on the 8th floor, 1 E sized oxygen tank was observed to be stored directly on the floor without a cart or chain. Additionally, storage of 16 E sized oxygen tanks were noted within the Physical Therapy gym located on the 4th floor. The tanks were stored near the exit door and within 5 feet of gym equipment. In an interview on 9/18/2017 at approximately 11am with the Director of Engineering, he stated he could relocate the oxygen tanks. 2012 NFPA 99 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedOctober 30, 2017

1. When it was brought to the attention of the Director of Engineering by the surveyor that there was unlawful and unsecure quantity of E sized oxygen tanks stored on the 8th floor by the nursing station and 4th floor in the physical therapy gym, they were immediately removed and brought to a secure location.
2. Immediately an inspection was conducted throughout the facility to ensure all E tanks are stored in an approved holding area with limited combustible construction and secured against unauthorized entry. No other areas were found to be non-compliant.
3. All staff throughout the building have been in-serviced on the handling, securing and storing of E tanks. All staff were also in-serviced on the importance of storing tanks 5 ft. away from any combustible materials. In-servicing also included any unlawful quantity which are stored in an approved holding area; ie E tanks should not be stored unless the proper size of the room is determined.
4. A Daily visual inspection will be conducted by the maintenance department along with nursing and rehab department to ensure all E tanks are stored and secured safely. As part of the monthly engineering QA audit, E tank storage will be documented and submitted to the administrator for review.
5. Responsible party: Director of maintenance or 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: September 18, 2017
Corrected date: November 15, 2017

Citation Details

2012 NFPA 101: 19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. 2012 NFPA 101: 9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following: (1) NFPA 13, Standard for the Installation of Sprinkler Systems (2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes (3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height 2010 NFPA 13: 8.15.3.2.2 Where noncombustible stair shafts are divided by walls or doors, sprinklers shall be provided on each side of the separation. Based on observation and staff interview, the facility was not protected throughout by an approved, supervised sprinkler system in that areas within the building were not provided with automatic sprinkler coverage. Examples were noted in two of four stairwells in the building. The findings are: On 9/15/17 between 10:00am- 1:00pm during the recertification survey, the following areas were noted lacking automatic sprinkler coverage: Within Stair C and D, sprinklers were lacking on either side of the doors to the basement. In an interview on 9/15/17 at approximately 12:05pm, the Director of Engineering stated that he will have the sprinkler heads added. 2012 NFPA 101: 19.3.5.1, 9.7.1.1 2010 NFPA 13: 8.15.3.2.2 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedOctober 30, 2017

1. When it was brought to the attention of the Director of Engineering by the surveyor that an approved supervised sprinkler system was lacking in the following areas:
Staircase C between first floor and cellar & Staircase D between first floor and cellar.
An approved supervised automatic sprinkler system was added by a certified fire suppression vendor to those areas to comply with NFPA 101: 19,3.5.1
2. A complete in-depth inspection was conducted by the Director of Maintenance throughout the facility to ensure all areas are protected by the buildings fire suppression system.
3. All maintenance staff was in-serviced on the fundamentals and importance of an automatic sprinkler system throughout the facility. In-servicing included notifying the director of engineering if certain areas throughout the facility were not in compliance, and if missing sprinkler heads need to be rectified.
4. An annual visual inspection of the automatic sprinkler system will be conducted by the Engineering Director to ensure all areas are covered under NFPA 13. This QA will be reviewed by the administrator for compliance.
5. Responsible party: Director of maintenance or 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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 18, 2017
Corrected date: November 15, 2017

Citation Details

2012 NFPA 101: 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested , and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2011 NFPA 25: 5.3.2.1 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. 2011 NFPA 25: 5.4.1.4* A supply of spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced. 2011 NFPA 25: 5.4.1.4.1 The sprinklers shall correspond to the types and temperature ratings of the sprinklers in the property. 2011 NFPA 25: 6.2.1 Components of standpipe and hose systems shall be visually inspected annually or as specified in Table 6.1.1.2. 2011 NFPA 25: Table 6.1.1.2 Summary of Standpipe and Hose Systems Inspection, Testing, and Maintenance. Test Item Frequency Reference Hose 5 years/ 3 years NFPA 1962 2008 NFPA 1962: 4.3.2 In-service hose designed for occupant use only shall be removed and service-tested as specified in Chapter 7 at intervals not exceeding 5 years after the date of manufacturer and every 3 years thereafter. 2011 NFPA 25: 13.4.4.2.2* Each dry pipe valve shall be trip tested annually during warm weather. 2011 NFPA 25: 13.4.4.2.2.2* Every 3 years and whenever the system is altered, the dry pipe valve shall be trip tested with the control valve fully open and the quick-opening device, if provided, in service. Based on observation, staff interview and documentation review, automatic sprinkler and standpipe systems were not inspected, tested , and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems in that: 1) pressure gauges serving the sprinkler system were not being tested or replaced every 5 years; 2) the facility did not provide spare sprinklers of each type and temperature rating installed throughout the building; 3) the facility did not test hoses as per NFPA 25 & NFPA 1962; and 4) the last documented dry pipe valve trip test was conducted on 8/23/13. The findings are: On 9/15/17 between 10:00am- 1:00pm during the recertification survey, the following was noted: 1) Pressure gauges serving both the wet and dry sprinkler systems were not being tested or replaced every 5 years. Examples are: a. Two pressure gauges on the fire pump had manufacture dates of 2009 and 2010. b. Two pressure gauges on the dry valve had manufacture dates of 2011. There was no documentation provided at the time of the survey to indicate that the pressure gauges were replaced or calibrated within the last 5 years. In an interview on 9/15/17 at approximately 11:50am, the Director of Engineering stated that he would address the issue. 2) The facility did not provide spare sprinklers of each type and temperature rating installed throughout the building. The facility only had spare upright and pendent type sprinkler heads and lacked spares of sidewall, concealed and dry type sprinklers. In an interview on 9/15/17 at approximately 11:45am, the Director of Engineering stated that he would get the spares. 3) The facility did not test hoses as per NFPA 25 & NFPA 1962. Examples include but are not limited to: hoses within Stairs A, C & D at the sub-basement level and Stair C at the basement level were observed with manufactured dates of 2005. At the time of the survey, the facility could not provide documentation indicating that the hoses were tested since the date of manufacture. In an interview on 9/18/17 at approximately 11:00am, the Director of Engineering stated that he did not have documentation for the hose testing. 4) The last documented dry pipe valve trip test was conducted on 8/23/13 by the Fire Department of New York (FDNY). There was no documentation provided at the time of the survey for an annual trip test and a 3-year full flow trip test conducted since 8/23/13. In an interview on 9/15/17 at approximately 11:55am, the Director of Engineering stated that he would look for documentation of the last trip test. 2012 NFPA 101: 9.7.5 2011 NFPA 25: 5.3.2.1, 5.4.1.4, 5.4.1.4.1, 6.2.1, 6.1.1.2, 13.4.4.2.2, 13.4.4.2.2.2 2008 NFPA 1962: 4.3.2

Plan of Correction: ApprovedOctober 30, 2017

1. When it was determined that the facility was not in compliance in the following areas related to NFPA 101 Sprinkler System ? Maintenance and Testing:
a. Pressure gauges serving both wet and dry sprinkler system were not tested or replaced within 5 years. - A certified fire suppression vendor was retained and the 5 year test was completed.
b. The facility did not provide spare sprinklers of each type and temperature rating installed throughout the building. - Spare sprinkler heads of each type were purchased and are being held with the Engineering department.
c. The facility did not test hoses as per NFPA 25 & NFPA 1962. - A certified fire suppression vendor was retained and hoses were tested .
d. The last documented dry pipe valve trip test was conducted on 8/23/13. - A dry valve trip test was conducted and completed.
2. The engineering department reviewed the NFPA 101 Sprinkler system code with a certified fire suppression vendor to determine if there were any other areas which were not in compliance. None were found to exist.
3. All maintenance staff was in-serviced on the importance on maintaining of water based fire protection system. The maintenance Director and all Engineering staff inspected all pressure gauges attached to the fire suppression system. An in-depth inspection was also carried out on all fire hoses throughout the facility to determine compliance. A certified fire suppression vendor was retained by the facility to complete the following as per NFPA 25: standard for testing and maintaining of water- based fire protection system:
a. Test and replace all pressure gauge attached to the fire suppression system.
b. Supply spare sidewall, concealed and dry type sprinkler heads throughout the building.
c. Conduct three year full trip test along with FDNY representative.
4. A PM was created and a visual inspection will be conducted to the dry and wet gauge sprinkler system on an annual bases. The NFPA 101 code will also be reviewed annually to ensure compliance. This audit will be conducted annually by the director of engineering and reviewed by the administrator.

5. Responsible party: Director of maintenance or designee

K307 NFPA 101:VERTICAL OPENINGS - ENCLOSURE

REGULATION: Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 18, 2017
Corrected date: November 1, 2017

Citation Details

Based on observations and staff interview, it was determined that the facility did not ensure that openings or penetrations were sealed properly by fire resistive material. This was noted on two of nine floors. The finding is: On (MONTH) 18 (YEAR) at approximately 11:00 am during the Life Safety recertification survey, it was observed that a porter's closet on the second floor had an approximately 4 inch by 3 inch unsealed opening in the ceiling. Also, paper towels were observed filling the penetration around telephone wires instead of a UL listed fire resistive material in the telephone closet area on the third floor. In an interview with the Director of Maintenance on 09/18/17 at approximately 11:15 am, he stated that all penetrations will be sealed properly. NFPA 101 2012 19.3.1.1 NYCRR 415.29(a)

Plan of Correction: ApprovedOctober 30, 2017

1. When it was brought to the attention of the Director of Engineering by the surveyor that the 2nd floor porter closet had a 4 inch by 3 inch unsealed opening which had paper towels filling the penetration and the 3rd floor telephone room had a penetration which was not filled with a UL listed fire resistive material; the material was removed and all holes were sealed with a UL listed fire resistive material which provides a 2-hour fire resistance rating.
2. All vertical openings and enclosures throughout the building have been inspected for penetration. No penetrations were found that required sealing.
3. An existing PM has been upgraded to incorporate all missing vertical openings. A policy has been created and presented to all certified vendors in regards to penetration throughout the building. An in-service was given to all maintenance staff on how to inspect vertical openings, as well as the importance and functions of using an approved UL listed fire resistive materials.
4. On a monthly basis the maintenance staff will inspect all vertical openings and enclosures to insure there are no unsealed penetrations. A quality assurance audit tool will be used to show if any penetrations have been found and the date they were corrected. This QA will be done by the director of engineering and reviewed by the administrator.
5. Responsible party: Director of Maintenance of designee