Mary Manning Walsh Nursing Home Co Inc
April 3, 2017 Certification 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: April 3, 2017
Corrected date: April 20, 2017

Citation Details

2011 NFPA96: 11.1.6 Cooking equipment shall not be operated while its fire-extinguishing system or exhaust system is nonoperational or impaired. 11.1.6.1 Where the fire-extinguishing system or exhaust system is nonoperational or impaired, the systems shall be tagged as noncompliant, and the owner or owner's representative shall be notified in writing of the impairment. Based on observation, documentation review, and staff interview, the facility failed to ensure that the Ansul system provided was operational and not impaired. This occurred in the kitchen of the facility. The finding is: On 3/29/2017 between the hours of 10am and 3pm during the recertification survey, the following was observed: In the Kitchen on the 7th floor of the facility, an Ansul system was observed above cooking equipment. Upon further inspection, the Ansul system contained a tag from the fire protection company indicating not in compliance. The inspection tag was dated (MONTH) (YEAR). Upon documentation review, it was noted that the system was functional but due to newly installed equipment, adjustments needed to be made to have a compliant system. In an interview on 3/29/2017 at approximately 2:15pm with the Food Services Director, he stated that the Ansul system still works, but some of the nozzles need to be relocated. In an interview on 3/29/2017 at approximately 2:30pm with the Corporate Director, he stated they are working on the non- compliant Ansul system. The changes were submitted for FDNY and NYC Department of Buildings and they are waiting approval before they can fix the system. 2012 NFPA 101 2011 NFPA 96 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedMay 3, 2017

Element #1 P(NAME) of affected area:
The Ansul system on the 7th floor kitchen was repaired and is now compliant. Repairs were completed on 4/20/2017.
Element #2 P(NAME) to identify areas potentially affected:

On 3/30/2017 the Engineering staff conducted inspections of all cooking equipment in the facility that is protected by an Ansul System to ensure systems are operational and not impaired. No similar conditions were noted.
Element #3 P(NAME) for facility measures to prevent re-occurrence:

Beginning 5/15/17 the Engineering Director/Designee as part of the environmental rounds team will conduct inspections each month to ensure all Ansul Systems in the facility are operational and not impaired.
Element #4 P(NAME) for monitoring corrective actions:
Beginning 5/22/17 the Director of Engineering/Designee will review weekly Environmental rounds for any cases where the Ansul System was operational and not impaired.
The Director of Engineering/Designee will report the results of these audits to the Quality Assurance (QA) Committee on a monthly basis for no less than 3 months and thereafter until such time that an acceptable level of compliance has been achieved as determined by the QA Committee.

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

REGULATION: Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 3, 2017
Corrected date: April 19, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, it was determined that the facility did not ensure that patient care related electrical equipment (PCREE) was inspected and maintained as per facility's policy as evidenced by PCREE observed with overdue inspection dates on inspection stickers or lacking inspection stickers. This was noted on 2 of 14 resident floors. The findings are: On 03/29/17 during the life safety recertification survey between 10:00 am to 3:00 pm, it was observed that PCREE in the facility were not inspected as per facility's maintenance program, examples include but are not limited to: - Resident room # 1013: a nebulizer was observed in the room and had an inspection sticker from Med Air repair with inspection date: 12/28/15 and inspection due date: 6/12/16. - Resident room # 621: a nebulizer was observed in the room and had an inspection sticker from Med Air Repair with inspection date: 06/20/16 and inspection due date: 01/05/17. - Resident room [ROOM NUMBER]: the resident's bed air pressure device had only a H&R Healthcare sticker that lacked inspection date. In an interview on 03/29/17 with the facility's Corporate Director (CD), he stated that the facility's policy regarding maintenance of PCREE included the rental of air pressure devices from H&R Healthcare and other equipment such as nebulizers were maintained by Med Air repair. The CD further stated that the observed devices were removed from use. 2012 NFPA 101 711.2(a)(1)

Plan of Correction: ApprovedMay 3, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element #1 P(NAME) of affected area:
On 4/1/17 Med Air Medical performed inspections and placed inspection stickers to the following equipment:
1. Nebulizer in resident room [ROOM NUMBER]
2. Nebulizer in resident room [ROOM NUMBER]
3. Bed Air pressure device in room [ROOM NUMBER]
Element #2 P(NAME) to identify areas potentially affected:
On 4/1/17 through 4/19/17 the Engineering staff performed inspections throughout the facility to ensure all patient care related equipment (PCREE) were inspected and inspection stickers were current and in place.
Element #3 P(NAME) for facility measures to prevent re-occurrence:
The Director of Engineering/Designee will review weekly Environment rounds for cases of PCREE that were not inspected, has overdue inspection stickers or inspection stickers were not in place. 2 Resident units will be inspected per week. Engineering staff will receive in-service education related to NFPA 101- Electrical Equipment- Testing and Maintenance Requirements.
Element # 4 P(NAME) system for monitoring compliance:
On a monthly basis, The Engineering Department will ensure that PCREE in at at least 10% of resident rooms and care areas will be checked for valid inspection.
The Director of Engineering/Designee will report the results of these audits to the Quality Assurance Committee on a monthly basis or until such time that an acceptable level of compliance has been achieved.

K307 NFPA 101:HAZARDOUS AREAS - ENCLOSURE

REGULATION: Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 3, 2017
Corrected date: May 12, 2017

Citation Details

Based on observation and staff interview, it was determined that the facility did not ensure that doors protecting hazardous areas were made self-closing as evidenced by doors to the 6th floor wheelchair storage room and Medical record office that lacked self-closing devices. This was noted on 1 of 16 floors. The findings are: On 03/29/2017 during the life safety recertification survey at approximately 12:30 pm, it was observed that the door to the wheelchair storage room located on the 6th floor lacked a self-closing device. In a subsequent observation of the Medical records office located on the 6th floor, it was noted that the room was used to store numerous paper charts in open shelving units, and the door to the corridor lacked a self-closing device. In an interview on 03/29/17 with the facility's Corporate Director, he stated that the doors will be fixed. 2012 NFPA 101

Plan of Correction: ApprovedMay 4, 2017

Element #1 P(NAME) of affected area:
Self-closing devices will be installed on wheelchair storage room door on 6th floor and also on the Medical Records office door located on the 6th floor. Work was completed on 3/29/2017.
Element #2 P(NAME) to identify areas potentially affected:

Beginning 4/6/2017 the Engineering Department staff conducted inspections of the entire facility to ensure doors protecting hazardous area self-closing. No similar conditions were noted.
Element #3 P(NAME) for facility measures to prevent re-occurrence:

Beginning (MONTH) 1st (YEAR) the Director of Engineering/Designee as part of Environment rounds Team will conduct weekly inspections on a portion of the facility to ensure all doors protecting hazardous areas are self-closing. Engineering staff will receive in-service education regarding NFPA Hazardous Areas- Enclosure. Any area found to be non-compliant will be addressed immediately.
Element #4 P(NAME) for monitoring corrective actions:
Beginning (MONTH) 1st (YEAR) the Director of Engineering/Designee will review weekly environment rounds for any cases where doors protecting hazardous areas continue to fail to self-close.
The Director of Engineering/Designee will report the results of these audits to the Quality Assurance Committee on a monthly basis or and until such time that an acceptable level of compliance has been achieved.

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 3, 2017
Corrected date: May 20, 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 3 of 6 floors of the facility. The findings are: On 3/28/2017 and 3/29/2017 between the hours of 9am and 3pm during the recertification survey, the following was observed: At the nursing station on the 11th floor, 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. The same situation occurred in the corridors on the 9th and 8th floors. In an interview on 3/29/2017 at approximately 10am with the Corporate Director, he stated he could rearrange the light switches for the night lights so they will be permanently lit. 2012 NFPA 101 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedMay 3, 2017

Element #1 P(NAME) for affected areas:
Minimum illumination will be provided on egress corridors on the 11th, 9th and 8th floors. Work will be completed by (MONTH) 20th (YEAR)
Element #2 P(NAME) for facility measures to prevent re-occurrence:

On (MONTH) 1st (YEAR) the Engineering staff conducted inspection of the entire facility to ensure all egress corridors in the facility are in compliance with 2012 NFPA 101: 7.8.1.1 and are either continuously in operation or capable of automatic operation without manual intervention.
Element #3 P(NAME) for facility measures to prevent re-occurrence:
On (MONTH) 1st (YEAR) the Director of Engineering/Designee as part of the Environment Rounds Team will conduct inspections of a portion of the facility on a weekly basis to ensure egress corridors are provided with minimum illumination as per 2012 NFPA 101 Illumination of Means of Egress. Engineering staff will receive in-service education regarding NFPA 101 Illumination of Means of Egress.
Element #4 P(NAME) for monitoring corrective actions:
Beginning (MONTH) 1st (YEAR) the Director of Engineering/Designee will review weekly Environmental Rounds for any case where the minimum illumination of egress corridors is not met.
The Director of Engineering/Designee will report the results of these audits to the Quality Assurance Committee on a monthly basis or and until such time that an acceptable level of compliance has been achieved.

K307 NFPA 101:RAMPS AND OTHER EXITS

REGULATION: Ramps and Other Exits Ramps, exit passageways, fire and slide escapes, alternating tread devices, and areas of refuge are in accordance with the provisions 7.2.5 through 7.2.12. 18.2.2.6 to 18.2.2.10 or 19.2.2.6 to 19.2.2.10

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 3, 2017
Corrected date: May 20, 2017

Citation Details

Based on observation and staff interview, it was determined that the facility did not ensure that handrails were provided in the exit ramp leading to outside of the facility. This was observed on the main floor. The Finding is: On (MONTH) 28, (YEAR) between the hours of 10:00 am and 3:00 pm during the recertification survey, a mini ramp (change in elevation) was observed on the main floor leading to 71st avenue. Further observation revealed that no handrail(s) were observed on both sides of this area. Residents have access to this area in the event of an emergency situation. In an interview with the Maintenance Director and Engineer on 3/28/17 at approximately 2:00 pm, they stated that handrails will be provided. 2012 NFPA 101: 19.2.2.6 to 19.2.2.10

Plan of Correction: ApprovedMay 3, 2017

Element #1 P(NAME) of affected area:
Handrails will be provided on both sides of the exit ramp on the main floor leading to 71st street. Work will be completed by (MONTH) 20th (YEAR).
Element #2 P(NAME) to identify areas potentially affected:
On 4/20/2017 the Engineering staff conducted inspection of the entire facility to ensure handrails were provided to the outside of the facility in all applicable areas.
Element #3 P(NAME) for facility measures to prevent re-occurrence:

Beginning (MONTH) 1st (YEAR), the Director of Engineering/Designee as part of Environment Rounds Team will conduct inspections of 2 resident units or facility egress areas to ensure handrails are provided in exit ramp leading outside of the facility. Engineering staff will receive In-service education regarding NFPA Ramps and Other Exit requirements.
Element #4 P(NAME) for monitoring corrective actions:
Beginning (MONTH) 1st (YEAR) the Director of Engineering/Designee will review weekly environment rounds, described above, for any cases of missing handrails in exit ramps leading to outside of the facility.
The Director of Engineering/Designee will report the result of these audits to the Quality Assurance Committee on a monthly basis and until such time that an acceptable level of compliance has been achieved.

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: April 3, 2017
Corrected date: April 15, 2017

Citation Details

Based on observation and staff interview, it was determined that the facility did not ensure that all areas in the facility were provided with an approved, supervised automatic sprinkler system as evidenced by the facility's 7th floor mechanical room that lacked sprinklers. This was noted on 1 of 16 floors of the facility. The findings are: On 03/29/2017 during the life safety recertification survey at approximately 12:45 pm, it was observed that the Mechanical room located on the 7th floor of the facility was not provided with sprinkler coverage. In an interview on 03/29/17 with the facility's Corporate Director, he stated that the issue will be addressed immediately. 2012 NFPA 101 2010 NFPA 13 711.2(a)(1)

Plan of Correction: ApprovedMay 3, 2017

Element #1 P(NAME) of affected area:
The mechanical room located on the 7th floor was provides with sprinkler coverage. Work was completed 4/15/17.
Element #2 P(NAME) to identify areas potentially affected:

Beginning 4/27/2017 the Engineering Department staff conducted inspections throughout the facility to ensure that all areas are provided with an approved supervised automatic Sprinkler System. No similar conditions were noted.
Element #3 P(NAME) for facility measures to prevent re-occurrence:

The Engineering Director/Designee as part of Environment rounds team will conduct inspections to ensure all areas are provided with an approved supervised automatic sprinkler system.
Element #4 P(NAME) for monitoring corrective actions:
Beginning 5/1/17 the Director of Engineering/Designee will review weekly Environmental rounds to identify any cases of areas in the facility that is not provided with an approved supervised automatic sprinkler system.
The Director of Engineering/Designee will report the results of these audits to the Quality Assurance Committee on a monthly basis or until such time that an acceptable level of compliance has been achieved.

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 3, 2017
Corrected date: May 28, 2017

Citation Details

2012 NFPA 101: 19.3.7.8 Doors in smoke barriers shall comply with 8.5.4 and all of the following: (1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7. (2) Latching hardware shall not be required (3) The doors shall not be required to swing in the direction of egress travel. 2012 NFPA 101: 8.5.4.4 Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1. 2012 NFPA 101: 7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. 2010 NFPA 105: 4.1.1 Fire door assemblies that are intended for use as smoke door assemblies shall also comply with NFPA 80, Standard for Fire Doors and Other Opening Protectives. 2010 NFPA 80: 4.2.1* Listed items shall be identified by a label. Based on observation and staff interview, the facility did not ensure that fire-rated doors were provided with a legible fire-rated label. This was noted on three of six floors. The findings are: On 3/28/2017 and 3/29/2017 between 9am- 3pm during the recertification survey, fire-rated doors were not provided with fire-rated labels. Examples include but are not limited to the smoke barrier doors on the 11th, 9th and 8th floors. In an interview on 3/29/17 at approximately 10:20am, the Corporate Director stated that he most of the doors are original will have to check if they have the ratings. 2012 NFPA 101: 19.3.7.8, 8.5.4.4, 7.2.1.15.2 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedMay 3, 2017

Element #1 P(NAME) of affected area:
Fire-rated labels will be provided on fire rated doors on the 11th, 9th, and 8th floors. Work will be completed by 5/28/17.
Element #2 P(NAME) to identify areas potentially affected:

The Engineering Department staff conducted inspections of the entire facility to ensure that fire rated labels are provided on all fire rated doors. No similar conditions were noted.
Element #3 P(NAME) for facility measures to prevent re-occurrence:

Beginning 5/15/2017 the Director of Engineering/Designee as part of Environment Round Team will conduct weekly inspections on 2 resident care areas or service areas to ensure fire rated labels are installed on all fire rated doors. Engineering staff will receive in-service education related to NFPA 101- Subdivision of Building Spaces- Smoke Barriers.
Element #4 P(NAME) for monitoring corrective actions:
Beginning 5/22/17 the Director of Engineering/Designee will review weekly Environmental rounds to identify any cases of fire rated doors that are missing fire rating labels.
The Director of Engineering/Designee will report the results of these audits to the Quality Assurance Committee on a monthly basis or until such time that an acceptable level of compliance has been achieved.