The Plaza Rehab and Nursing Center
June 28, 2018 Certification Survey

Standard Life Safety Code Citations

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 11, 2018
Corrected date: August 10, 2018

Citation Details

Section 7.2.1.5.1 states that doors shall be arranged to be opened readily from the egress side whenever the building is occupied. This standard is not met as evidenced by: Based on observation, it was determined that the facility did not ensure that the egress doors from use areas were free of any locking device that could not be operated from the egress side. Reference is made to the egress doors from the storage closets in the vicinity of exit stair E on resident floors in the Plaza East building, and the doors to the resident room closets (room #'s 1002, 1003, 1006, 1016 and 1018) that were equipped with dead bolt type or other locking devices on the outside of the doors that could not be operated from the egress side of the closets. The findings include: On 7/9/18, 7/10/18 and 7/11/18, between 10:00 AM and 3:00 PM,during the recertification survey, it was observed that the facility had installed dead-bolt type or other locking devices on the outside of the door to the storage closets/rooms located in the vicinity of exit stair E on resident floors in the Plaza East building, and the doors to the resident room closets (room #'s 1002, 1003, 1006, 1016 and 1018), in the Plaza East building. These locking devices, when engaged, could not be opened from the egress side of the room/closets. The egress doors from the use areas must be free of any locking devices that could not be opened from the egress side. On 7/11/18 at approximately 11:30 AM, the facility's Director of Engineering stated that all locking devices installed on the outside of the doors to use areas were being removed. 711.2 (a)(1) 2012 NFPA 101

Plan of Correction: ApprovedJuly 24, 2018

1. All locking devices installed on the outside of the closet doors located in Residents room #?s 1002, 1003, 1006, 1016 and 1018 were removed. Deadbolt locks on the Recreation Closets next to Stair E were disabled in the Plaza East Bldg on 7/11/18.
2. No residents were affected by this deficient action, however all residents in the above listed rooms had the potential to be affected. All risk was eliminated.
3. Plant Operation Manager?s will check and asses all doors throughout the entire building and ensure all are made compliant to NFPA 101 Means of Egress. All maintenance staff were informed to report any other such occurrences.
4. Director of Plant Operations will conduct weekly Environment of Care rounds to ensure compliance.
5. Compliance would be reported in QA&A meetings quarterly.

K307 NFPA 101:SMOKE DETECTION

REGULATION: Smoke Detection 2012 EXISTING Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1. 19.3.4.5.2

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 11, 2018
Corrected date: July 25, 2018

Citation Details

Based on observation and staff interview, it was determined that the facility did not ensure that the open spaces to the corridor were provided with a smoke detection system, as per 19.3.6.1. Reference is made to the sections of Galeria on the first floor of the Plaza West building and the sitting area on the 2nd floor in the Plaza West building that were open to the corridor and lacked a smoke detection system. The findings include: On 7/9/18, 7/10/18 and 7/11/18, at 10:00 AM to 3:00 PM, during the recertification survey of the facility, it was observed that in the Plaza West building the sections of Galeria (vending machine and the sitting area) on the first floor, and the sitting area on the 2nd floor, were open to the exit access corridor with no wall/door. These open areas lacked the required smoke detection system as per 19.3.6.1. On 7/11/18 at approximately 12:00 PM, the facility's Director of Engineering stated that all open areas to the egress corridor will be provided with the required smoke detection system. 711.2 (a)(1) 2012 NFPA 101

Plan of Correction: ApprovedJuly 24, 2018

1. Smoke detectors will be installed in the Plaza West 1st floor Galleria sitting area and 2nd floor Lounge by a certified Fire Alarm contractor to comply with NFA 101 2012 Existing Smoke Detection and it will be completed (MONTH) 25, (YEAR).
2. No residents were affected by the deficiency identified, however all residents have the potential to be affected.
3. Plant Operations Managers will survey all sitting and lounge areas throughout the building with a certified smoke detector installer for proper location. Completed (MONTH) 13, (YEAR).
4. Compliance would be monitored by Plant Operations Director weekly on Environment of Care rounds and reported Quarterly to QA&A meeting.
5. Plant Operations Director will perform weekly Environment of Care rounds to ensure compliance to smoke detection system and completed (MONTH) 25, (YEAR)

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 11, 2018
Corrected date: September 6, 2018

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 lack of sprinkler coverage for a number of areas in the building, examples include: In the main food storage area in the basement, sprinklers were obstructed by an approximately 12 inches high soffit; in the small section of the food storage area in the basement, a sprinkler was not installed within six feet of the wall; a sprinkler were not installed under the greater than four feet wide duct system in the electric shop; a section of the large overhang in the kitchen lacked sprinklers; an alcove containing a compressor for the drinking fountain on the 4th floor of Plaza East lacked a sprinkler; an alcove containing a lighting fixture in the female toilets' area in the Plaza East lacked a sprinkler;and the electrical closet on the 2nd floor of the Plaza East lacked sprinklers. The findings include: On 7/9/18, 7/10/18 and 7/11/18, between 10:00 AM and 3:00 PM, during the recertification survey, it was observed that automatic sprinklers were lacking or were obstructed in a number of areas of the building, so as not to provide coverage for the entire protected area, in accordance with NFPA 13. The examples included but not limited to the following: (1) In the Z building in the basement, a number of sprinklers were obstructed by an approximately 12 inches high soffit; so as not to provide coverage for the entire protected food storage area. (2) In the basement of Z building, the small food storage areas in the rear of the main food storage area, the sprinkler was not installed within six feet of the wall. The sprinkler was located approximately 11 feet from the wall. (3) In the basement of Z building in the small room at the rear of the main food storage area, a sprinkler was obstructed by the lighting fixture and the duct system so as not to provide coverage for the entire protected section of the room. (4) In the basement of Z building in the electric shop, the use area under approximately 7 ft wide duct system lacked sprinklers. (5) In the basement of the Plaza West building in the female locker room, sprinklers were obstructed by the shower stall enclosure wall/partition so as not to provide coverage for the entire protected area. (6) In in the kitchen area of the Plaza West building, sprinklers were lacking under the approximately six ft wide overhang containing the Blodgett pressure cookers. (7) In the female toilets' area located in the vicinity of the Galeria on the first floor of the Plaza West building, a sprinkler head was obstructed by the turn of the wall so as not to provide coverage for the second alcove containing a handwashing sink and a lighting fixture. (8) In the Plaza West building on the 2nd floor, the electrical closet of the Saul unit lacked sprinklers. The electrical closet did not comply with the exception rules, as an unprotected ventilation opening existed in the closet wall. (9) In the Plaza West building, a 4th floor alcove containing a drinking fountain and a compressor lacked sprinkler coverage. The existing sprinkler in the vicinity of the alcove was obstructed by the turn of the wall. (10) In the Plaza West building in the central bathing area on the 4th floor, an alcove area containing a lighting fixture and storage cabinets, lacked sprinkler coverage. The existing sprinkler in the vicinity of the alcove was obstructed by the wall so as not to provide coverage for the entire protected area. On 7/11/18, at approximately 2:00 PM, the facility's Director of Engineering stated that the sprinkler company will be contacted to evaluated and provide sprinklers in all areas of the building, in accordance with NFPA 13. 711.2 (a)(1) 2012 NFPA 101 2012 NFPA 13

Plan of Correction: ApprovedJuly 24, 2018

1.A certified Plumbing and Sprinkler Contractor will start 7/20/18 to install, relocate and modify locations of sprinkler heads to provide proper coverage for the cited areas located in Plaza West and ?Z? Building. Installation and pressure testing will be completed 7/25/18.
2.No residents were affected by the deficiency identified, however all residents have the potential to be affected.
3.Director and Managers of Plant Operations will check all other areas throughout the Facility to ensure proper sprinkler coverage in compliance with NFPA 101 2012.Existing Sprinkler System Installation will be completed on 7/25/18.
4. Director of Plant Operations will conduct weekly Environment of Care rounds to ensure compliance with 2012 NFPA13.
5.Compliance would be monitored and reported in quarterly QA&A meeting

K307 NFPA 101:STAIRWAYS AND SMOKEPROOF ENCLOSURES

REGULATION: Stairways and Smokeproof Enclosures Stairways and Smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 11, 2018
Corrected date: August 5, 2018

Citation Details

Section 7-1.8, 2012 NFPA 101 states that guards in accordance with 7.2.2.4 shall be provided at the open side of the means of egress that exceed 30 inches (760 mm) above the floor or the finished ground level below. This standard is not met as evidenced by: Based on observation, it was determined that the facility did not ensure that guards provided at the open side of the exit stair landings were at least 42 inches high as per 7.2.2.4. Reference is made to the guards provided at landings on the top of the exit stair that were approximately 36 inches above the landing floor instead of the required minimum of 42 inches high from the stair landing floor. The findings include: On 7/9//18, 7/10/18 and 7/11/18, between 10:00 AM to 3:00 PM, during the recertification survey of the facility, it was observed that the facility had provided guards at the open side of the exit stair landings. The guards provided on the top landings of the exit stair D and F in the Plaza East building measured approximately 36 inches high from the landing floor instead of the minimum of 42 inches high from the landing floor. On 07/11/18 at approximately 12:30 PM, the facility's Director of Engineering stated that guardrails at all stair landing will be extended to the required height. 711.2 (a)(1) 2012 NFPA 101

Plan of Correction: ApprovedJuly 24, 2018

1.A Certified Welding Contractor will install /modify guardrails to the required minimum height of 42 on Plaza East Stairway D and F landings. Completion date is (MONTH) 25, (YEAR).
2.No residents were affected by this deficiency, however all residents have the potential to be affected.
3.The Director of Plant Operations will inspect all stairwell landings throughout the facility to comply with NFPA 101 Stairway and Smoke proof Enclosures, during weekly Environment of care rounds.
4.Completion date is (MONTH) 5, (YEAR)
5. Compliance would be reported in QA&A meetings quarterly.

ZT1N 713-1:STANDARDS OF CONSTRUCTION FOR NEW EXISTING NH

REGULATION: N/A

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 11, 2018
Corrected date: July 25, 2018

Citation Details

713-1.9 Mechanical requirements. (d) Bathing rooms, soiled workrooms, soiled linen rooms and janitors' closets shall have mechanical exhaust ventilation or a wall or, if approved by the department, window exhaust fan with back-draft louvers. Based on observation (testing) and staff interview, the facility did not ensure that the exhaust ventilation was in proper working order. Reference is made to the bio-hazard room located in the Saltzman building. This was observed on 1 out of 6 floors. The Finding is: On (MONTH) 10, (YEAR) during the Recertification survey of the facility, it was observed that the exhaust return located in the sixth floor bio-hazard room of the Saltzman building was not in good working order when tested manually by the staff. In an interview with the Maintenance Director at approximately 2:30 pm, he stated that this concern will be immediately corrected.

Plan of Correction: ApprovedJuly 24, 2018

1. Engineering team members corrected and retested exhaust fan to ensure proper function; proper functioning was established as exhaust being provided at 10 air changes per hour. This was completed on 7/10/18.
2. No residents were affected by this noncompliance citation, however all residents have the potential to be affected by this deficient practice.
3. Plant Operations Managers will check all Exhaust fans in the entire building Weekly and sign exhaust fan maintenance logs. On going
4. Director of Plant Operations will audit and inspect exhaust fans to ensure compliance to standard.
5. Compliance audit would be reported in Quarterly QA&A meeting.

ZT1N 713-2:STANDARDS OF CONSTRUCTION FOR NEW NH

REGULATION: N/A

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 11, 2018
Corrected date: August 17, 2018

Citation Details

NYCRR 713-2.21 (e)(2) (iii) Backflow preventers (vacuum breakers) shall be installed on hose bibbs,janitor's sinks, bed pan flushing attachments and on all other fixtures to which hoses or tubings can be attached. This requirement is not met as evidenced by: Based on observation and staff interview, it was determined that the facility did not ensure that vacuum breakers were installed on all other fixtures to which hoses tubings can be attached. Reference is made to the water fixtures with attached flexible hose in the nourishment units off resident dining rooms in the Plaza East and Plaza West buildings, that lacked backflow preventers (vacuum breakers). The findings include : On 7/9/18, 7/10/18 and 7/11/18, between 10:00 AM and 3:00 PM, during the recertification survey, it was observed that the water fixtures installed for the utility sinks in the nourishment stations off the resident dining rooms in the Plaza East and Plaza West buildings,were provided with flexible metal type hoses attachments. The water fixtures with hoses attachments in these areas lacked vacuum breakers. On 7/11/18, at approximately 12:30 PM, the facility's Director of Engineering stated that all water fixtures with hoses attachments will be provided with backflow preventers (vacuum breakers).

Plan of Correction: ApprovedJuly 24, 2018

1. UL rated Manufacturer?s approved vacuum breakers were installed by engineering team members on all flexible water fixtures with hoses located in Plaza East and Plaza West buildings pantries. Completed on 7/17/18.
2. No residents were affected by the deficiency; numerous residents have the potential to be affected by this deficient practice.
3. Plant Operations managers will survey water fixtures with hoses throughout the building to ensure vacuum breakers or backflow preventers are installed. Completed by (MONTH) 25, (YEAR)
4. The Director of Plant Operations will conduct weekly environment of care audits to check water fixtures with hoses are compliant with NYCRR 713-2.21
5. Compliance would be reported in QA&A meetings quarterly.