Buena Vida Rehabilitation and Nursing Center
August 11, 2017 Certification Survey

Standard Life Safety Code Citations

K307 NFPA 101:DOORS WITH SELF-CLOSING DEVICES

REGULATION: Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 11, 2017
Corrected date: September 22, 2017

Citation Details

2012 NFPA101:19.2.2.2.7* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm systems required by 7.2.1.8.2, shall be arrange to initiate the closing action of all such doors throughout the entire facility. Based on observations and staff interview, the facility failed to ensure that doors comply with NFPA 101, 2012 edition regulations. Specifically, doors to hazardous areas were not provided with the appropriate self-closing device and/ or did not automatically latch. This was noted on 1 of 8 floors and the basement. The findings are: On 8/10/17 and 8/11/2017 between the hours of 9am and 2:30pm, during the recertification survey, the following was observed: Doors to hazardous areas either lacked a self- closing device or, contained a non-compliant hold open device. Locations include, but are not limited to: 1- 6th Floor Sensory/ Recreation Storage Room 2- Basement Food Storage Room In an interview on 8/10/2017 at approximately 10:20am with the Director of Facilities Management, he stated he could relocate the recreation storage from the room. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.2.2.2.6, 7.2.1.8.2

Plan of Correction: ApprovedSeptember 21, 2017

All aspects will be remedied in accordance with NFPA101:19.2.2.2.7.
1- 6th floor Sensory / Recreation storage room all storage items were removed on (MONTH) 11, (YEAR).
2- Basement food storage room door was held open. All food service employees were in-serviced on door closure regulations.
Additionally all areas of the facility will be reviewed for similar deficiencies as noted
Responsible party(NAME)Levitt, Director of Facilities.
These areas as noted will be added to our monthly Environmental Rounds checklist. The Plan of Correction and review for continued compliance will be added to the monthly Quality Assurance Committee agenda for review.
Responsible party(NAME)Levitt, Director of Facilities

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 11, 2017
Corrected date: September 22, 2017

Citation Details

2012 NFPA 101: 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 43. 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 the public way. 7.8.1.3* The floors and other walking surfaces within an exit and within the portions of the exit access and exit discharge designated in 7.8.1.1 shall be illuminated as follows: (1) During conditions of stair use, the minimum illumination for new stairs shall be at least 10 ft-candle (108 lux), measured at the walking surfaces. (2) The minimum illumination for floors and walking surfaces, other than new stairs during conditions of stair use, shall be to values of at least 1 ft-candle (10.8 lux), measured at the floor. (3) In assembly occupancies, the illumination of the walking surfaces of exit access shall be at least 0.2 ft-candle (2.2 lux) during periods of performances or projections involving directed light. (4)*The minimum illumination requirements shall not apply where operations or processes require low lighting levels. 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. Based on observation and staff interview, the facility failed to ensure that egress corridors were provided with minimum illumination. This was observed on 1 of 8 floors of the facility. The findings are: On 8/11/2017 at approximately 10:35am during the recertification survey, the following was observed: On the 1st floor, in the administrative offices corridor near the elevators, a panel of light switches was observed. When in the off position, the corridor was in darkness and no lighting fixtures were observed to be illuminated. In an interview on 8/11/2017 at approximately 10:35am with the Lead Mechanic, he stated he could rearrange the wiring so the lighting fixtures above the exit doors will remain on at all times. 2012 NFPA 101 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedSeptember 21, 2017

All aspects as noted will be remedied in accordance with2012 NFPA101: 7.8.1.1.
The first floor Administrative corridor is in darkness when light switches are in the off position.
Every other light fixture has been hard wired to stay on at all times which was completed on (MONTH) 11, (YEAR).
Additionally all areas of the facility will be reviewed for similar deficiencies as noted.
This will be incorporated into Maintenance rounds to ensure compliance.
Responsible person:(NAME)Levitt, Director of Facilities.
These areas as noted will be added to our monthly Environmental Rounds checklist. The Plan of Correction and review for continued compliance will be added to the monthly Quality Assurance Committee agenda for review.
Responsible party(NAME)Levitt, Director of Facilities

K307 NFPA 101:SMOKING REGULATIONS

REGULATION: Smoking Regulations Smoking regulations shall be adopted and shall include not less than the following provisions: (1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. (2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required. (3) Smoking by patients classified as not responsible shall be prohibited. (4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision. (5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. (6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. 18.7.4, 19.7.4

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 11, 2017
Corrected date: September 22, 2017

Citation Details

2012 NFPA 101: 19.7.4* Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions: (1) Smoking shall be prohibited in any room, ward, or individual enclosed space where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. (2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required. (3) Smoking by patients classified as not responsible shall be prohibited. (4) The requirement of 19.7.4(3) shall not apply where the patient is under direct supervision. (5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. (6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. Based on observation and staff interview, the facility did not ensure that ashtrays of a safe design with center rests and a metal container with a self-closing lid were provided in the outside smoking area. The findings are: On 8/11/17 at approximately 10:25am during the recertification survey, ashtrays of a safe design with a center rest and a metal container with a self-closing lid were not provided in the outside smoking area. A smoking outpost was provided in the outside smoking area in lieu of the required ashtrays and metal container. The outpost was not designed to allow a resident to put down their cigarette securely. In an interview on 8/11/17 at approximately 10:25am, the Director of Facilities Management stated that he can add the appropriate ashtrays. 2012 NFPA 101: 19.7.4 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedSeptember 21, 2017

All aspects as noted will be remedied in accordance with NFPA 101:19.7.4.
An ashtray of safe design with a center rest and a metal container with a self closing lid has been supplied and is in place as of (MONTH) 11, (YEAR)
This item as noted will be added to our Environmental Rounds monthly checklist. The Plan of Correction and review for continued compliance will be added to the monthly Quality Assurance Committee agenda for review.
Responsible Party:(NAME)Levitt, Director of Facilities.

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: Widespread
Severity: Potential to cause more than minimal harm
Citation date: August 11, 2017
Corrected date: September 22, 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 or the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 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: INSPECTION, TESTING, AND MAINTENANCE OF WATER-BASED FIRE PROTECTION SYSTEMS. 8.3.3 Annual Flow Testing. 8.3.3.1* An annual test of each pump assembly shall be conducted by qualified personnel under minimum, rated, and peak flows of the fire pump by controlling the quantity of water discharged through approved test devices. Table 13.1.1.2 Summary of Valves, Valve Components, and Trim Inspection, Testing, and Maintenance Item Frequency Reference Inspection. Check Valves Interior 5 years 13.4.2.1 This requirement is not met as evidenced by: Based on observation, documentation review, and staff interview, during the recertification survey, the following was noted: 1. It could not be determined that the fire hoses were tested and/or replaced as per NFPA 25 & NFPA 1962. This was noted within the stairwells on 8 of 8 floors inspected for compliance. 2. The facility did not provide documentation of the final sign off and records of maintenance of the ABC dry chemical system installed in the elevator motor room on the roof. 3. It could not be determined that the sprinkler system check valve was internally inspected within the last five years. 4. It could not be determined that an annual test of the electric fire pump was completed. During the Life Safety Code survey conducted on 08/10/17 and on 08/11/17, between 9:00am and 2:30pm, the following was noted: 1. The fire hoses within the stairwells (A&B stairwells) on floors 1-8 were noted with stamped manufactured dates between 02/2000 and 08/2000. There was no documentation provided of the hose testing conducted at five years after installation and at the subsequent three-year intervals. In an interview on 08/10/17 at approximately 9:30am, the Director of Building Services stated that the sprinkler company would be contacted to have all the hoses replaced. 2. During a review of the elevator motor room on the roof on 08/10/17 at approximately 9:15am, it was noted that the ABC fire suppression system did not have a service/maintenance tag attached to the system. Additionally, the facility did not submit evidence of a final signoff of the system from the local jurisdiction. In an interview at this time, the Director of Building Services stated that the suppression system was recently installed and that an application for an FDNY final inspection would be filed. Although the facility submitted an intent to correct the issues noted during the survey, it was determined that both issues were still outstanding at the conclusion of the recertification survey. 3. During a record review on 08/11/17 at approximately 12:30pm, it could not be determined that the check valve associated with the sprinkler system was internally inspected within the last five years. In an interview on the same day at approximately 12:30pm, the Director of Building Services stated that he would check with the sprinkler maintenance company and provide the invoice of the inspection as necessary. No documentation of the sprinkler system five-year check valve internal inspection was provided at the conclusion of the recertification survey. 4. During a record review on 08/11/17 at approximately 1:40pm, there was no documented evidence of an up to date annual full flow test of the electric fire pump associated with the sprinkler system. In an interview on the same day at approximately 2:30pm, the Director of Building Services stated that the documentation of an annual fire pump test would be provided if available or otherwise a full flow test of the fire pump would be immediately scheduled. No documentation of the annual fire pump test was provided at the conclusion of the recertification survey. 2012 NFPA 101: 9.7.5, 9.7.7, 9.7.8, and 2011 NFPA 25 2008 NFPA 1962 10NYCRR 711.2(a)(1) 10 NYCRR 415.29

Plan of Correction: ApprovedSeptember 21, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** All Aspects as noted will be remedied in accordance with NFPA 101:9.7.5.
1- All Fire Hoses within the facility have been replaced as of (MONTH) 25, (YEAR).
2- The elevator motor room ABC fire suppression system has had a pretest. We are awaiting the FDNY to schedule final inspection. Completion date by (MONTH) 10, (YEAR).
3- Check Valves were internally inspected (MONTH) 11, (YEAR).
4- Electric Fire Pump test will be completed on [DATE].
Responsible party:(NAME)Levitt, Director of Facilities.
A records review will be completed quarterly to ensure that all documents are onsite.
The Plan of Correction and review for continued compliance will be added to the monthly Quality Assurance Committee agenda for review.
Responsible party:(NAME)Levitt, Director of Facilities.