Manhattanville Health Care Center
March 17, 2017 Certification Survey

Standard Life Safety Code Citations

K307 NFPA 101:EXIT SIGNAGE

REGULATION: Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 17, 2017
Corrected date: May 16, 2017

Citation Details

Based on observation and staff interview, it was determined that the facility did not ensure that EXIT directional signs were in accordance with Section 7-10. This was observed in the kitchen area and third floor. The Findings include but not limited to: On (MONTH) 13, (YEAR) between the hours of 09:30 am, and 12:00 pm, it was observed that EXIT directional signs observed in the kitchen area, and third floor were not illuminated evenly and/or plainly legible, as evidenced by glare and faded letters. In an interview with the Administrator on (MONTH) 13, (YEAR) at approximately 2:45 pm, he stated that they are in the process of changing the EXIT lights and it will be corrected. 711.2 (a)(1) NFPA 101: 7.10

Plan of Correction: ApprovedApril 28, 2017

I. Immediate Correction:
The affected fixtures were replaced and made visible.
II. Identification
The engineer conducted a review of all exit fixtures and verified that all were functioning as designed and properly readable.
III. Systemic Changes:
The facility has implemented a weekly inspection of all exit fixtures.
Staff not responsible for lighting operation shall be inserviced on how to report a defective fixture.
IV. Quality Assurance
The exit light log shall be reviewed by the facility engineer and reports submitted to QAPI for review and recommendations of changes which may be determined by the routine reviews.
V. Person Responsible
The Facility engineer is responsible for monitoring and assignment completion for this task.

K307 NFPA 101:RUBBISH CHUTES, INCINERATORS, AND LAUNDRY CHU

REGULATION: Rubbish Chutes, Incinerators, and Laundry Chutes 2012 EXISTING (1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5. (2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7. (3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.) (4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use. 19.5.4, 9.5, 8.4, NFPA 82

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 17, 2017
Corrected date: May 16, 2017

Citation Details

Based on observation, it was determined that the facility did not ensure that the openings to the linen chute were protected with appropriate rated and latching doors. Reference is made to the doors protecting linen chute service openings that did not latch in their frames on the 5th floor and 6th floor. The findings include: On (MONTH) 13,2017 at 9:30 AM to 2:30 PM, it was observed that the doors protecting the linen chute service openings on the 5th and 6th floors were not latching in their frames. The door latches stayed retracted and did not protrude to latch in the door frame. On (MONTH) 13,2017 at approximately 11:30 AM, the facility's Director of Engineering stated that the linen chute door latches will be repaired or replaced to latch appropriately in the door frames. 711.2 (a)(1) 2012 NFPA 101

Plan of Correction: ApprovedApril 28, 2017

I. Immediate Correction:
The chute door on 5th and 6th floors were repaired and made to latch.
II. Identification:
A review was conducted for all other chute doors and none were found out of compliance
III. Systemic Changes:
The facility engineer has added weekly inspection of the chute system to preventive maintenance and shall assign maintenance staff to complete the audits. Staff shall be in serviced about the new policy and the procedures by the Facility Engineer including how to report a defective chute door.
IV. Quality Assurance:
The facility engineer in conjunction with the Administrator developed a log to monitor compliance with effective operation of chute doors. The log shall be reviewed by the facility engineer and reports submitted to QAPI for review and recommendations of changes which may be determined by the routine reviews.
V.Person(s) Responsible
The Administrator and the Facility engineer are responsible for monitoring and assignment completion for this task.

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: March 17, 2017
Corrected date: May 16, 2017

Citation Details

Based on observation, it was determined that the facility did not ensure that all areas in the building were protected by an automatic sprinkler system in accordance with section 9.7 and NFPA 13. Reference is made to the storage room located under the elevator machine room, that lacked automatic fire extinguishing system. The findings include: On (MONTH) 13,2017 at 9:30 AM to 2:30 PM, it was observed that the facility had a storage room constructed under the elevator machine room, at the roof level. The storage room lacked automatic fire extinguishing system. On (MONTH) 13, (YEAR) at approximately 12:00 PM, the facility's Director of Engineering stated that the facility will either provide sprinklers in the storage room or comply with exception rules of appropriate resistance fire rating of the enclosure walls and door protecting the opening to the storage room. 711.2 (a)(1) 2012 NFPA 101

Plan of Correction: ApprovedMay 2, 2017

I. Immediate Correction:
The facility has had all storage removed from the area and the restricted access now complies with NFPA 13.

Identification:
II. Identification:
A review of all other areas was conducted by the facility engineer and no other areas were found without proper NFPA 13 sprinkler coverage.
III. Systemic Changes:
Staff will be in serviced by the facility Engineer about utilizing concealed spaces for storage including exception 8.15.1.2.2 Concealed spaces of noncombustible and limited combustible
Construction 8.15.1.2.2 Concealed spaces of noncombustible and limited combustibleConstruction with limited access and not permitting occupancy or storage of combustibles shall not require sprinkler protection.
Lock will also be placed on crawl space door that director of maintenance will hold the copy
Facility engineer will assure that the hatch door on roof which is 35-3/4 x 34-1/2 will have a fire rating of 1.5 hours
IV.Quality Assurance
The engineer shall conduct monthly inspections of the area to maintain compliance with NFPA 13 8.1.15.1.2.2 and assure that door is locked. QAPI committee shall review any negative finding for corrective action and further implementation of reviews.
V.Person responsible
The Facility Engineer

ZT1N 713-2:STANDARDS OF CONSTRUCTION FOR NEW NH

REGULATION: N/A

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 17, 2017
Corrected date: May 16, 2017

Citation Details

Physical Plant Violation - State Only NYCRR 713-2.1(d) Heating and ventilating system shall comply with the following : (2)(i): Outdoor air intakes shall be located as far as practical but not less than 25 feet from exhaust outlets of ventilating systems, combustion equipment stacks, medical-surgical vacuum systems, plumbing vent stacks, or from areas which may collect vehicular exhaust and other noxious fumes. The bottom of outdoor air intakes serving central systems shall be located as high as practical but not less than six feet above ground level or if installed above the roof, three feet above roof level. This requirement is not met as evidenced by: Based on observation, it was determined that the facility did not ensure that the outdoor air intakes for the air handling equipment were located not less than twenty five feet from the plumbing vent stack and the air exhaust fans of the building. Reference is made to the outdoor air intakes for the facility air handling equipment A and B, on the roof, that were less than twenty five feet from the plumbing vent stack and the air exhaust fans The findings include : On (MONTH) 13, (YEAR) at 9:30 AM to 2:30 PM, it was observed that the facility had installed two air handling equipments (A and B), on the roof. The air intake for the air handler A was only approximately three feet from the plumbing vent stack and approximately fifteen feet from the toilet air exhaust fan. The air intake for the air handler B was approximately fifteen feet from the plumbing vent stack and from the toilet exhaust fans. The outdoor air intakes can not be closer than twenty five feet from any plumbing vent stack and/or the air exhaust fan. On (MONTH) 13, (YEAR) at approximately 11:00 AM, the facility's Director of Engineering stated that HVAC company will be contacted to evaluate and provide appropriate distance between the air intakes of the air handling equipment and the plumbing vent stacks and the air exhaust fans. NYCRR 713-2.21(d)(2)(viii) : A manometer shall be installed across each filter bed serving central air systems. This requirement is not met as evidenced by: Based on observation, it was determined that the facility did not ensure that a manometer was installed across each filter bed serving the central air system . Reference is made to the lacked of manometers across filter beds for the central air handling equipment A and air handling equipment B. The findings include: On (MONTH) 13, (YEAR) at 9:30 AM to 2:30 PM, it was observed that the facility had installed two central air handling equipments identified as A and B on the roof. Manometers were not installed for filter beds provided in connection with the central air handling equipment. On (MONTH) 13, (YEAR) at approximately 11:15 AM, the facility's Director of Engineering stated that HVAC company will be contacted to install the manometers across filter beds of all central air handling equipment.

Plan of Correction: ApprovedApril 28, 2017

I. Immediate Correction:
The facility engineer will specify the appropriate manometers and layout the required piping design to relocate the vent stacks or HVAC intakes so that in compliance with state construction code can be accomplished.
II. Identification:
The engineer shall review the installation of all other HVAC systems for compliance and his recommendations shall be implemented.
III. Systemic Changes
The facility has developed a policy for any future installations of having the plans reviewed by an architect/PE for compliance with all state construction codes.
IV. Quality Assurance:
The facility Engineer in conjunction with the Administrator developed an audit tool to monitor the facility?s compliance with all state and federal construction codes. This audit will be completed by the facility engineer for all facility construction projects. Any identified issues will be reported to QA Committee for input and follow up.
V. Person(s) Responsible:
The Administrator and Facility Engineer