East Haven Nursing & Rehabilitation Center
June 27, 2018 Certification Survey

Standard Life Safety Code Citations

K307 NFPA 101:CORRIDORS - CONSTRUCTION OF WALLS

REGULATION: Corridors - Construction of Walls 2012 EXISTING Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames. If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area. 19.3.6.2, 19.3.6.2.7

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 29, 2018
Corrected date: August 20, 2018

Citation Details

2012 NFPA 101: 19.3.6.2.7 Fixed fire window assemblies in accordance with Section 8.3 shall be permitted in corridor walls, unless otherwise permitted in 19.3.6.2.8. Based on observation and staff interview, an operable, sliding glass vision panel was observed in the corridor wall of the business office. This was noted on the Lobby level. The findings are: On 6/29/18 at approximately 11:45am during the recertification survey, an operable, sliding glass vision panel was observed in the corridor wall of the business office. In an interview on 6/29/18 at approximately 11:45am, the Director of Operations stated that they would permanently lock the window. 2012 NFPA 101: 19.3.6.2.7 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedJuly 27, 2018

K 362
1. IMMEDIATE CORRECTIVE ACTION TAKEN.
Upon identification on 06/29/2018 of an operable, sliding glass vision panel in the corridor wall of the business office that was noted on the lobby level, the facility maintenance staff permanently locked it on the same day.
2. THE FOLLOWING CORRECTIVE ACTIONS WERE IMPLIMENTED TO IDENTIFY OTHER AREAS THAT MAY BE AFFECTED.
The facility Director of Operations surveyed the other areas of the facility to assure compliance.
3. THE FOLLOWING MEASURES WERE PUT INTO PLACE TO ASSURE COMPLIANCE.
a) The facility Director of Operations and Administrator reviewed and revised the facility policy for use of sliding glass vision panel on Corridors ? Construction of walls.
b) The facility Director of Operations gave in-service training to the maintenance staff.
c) Audits will be performed by the facility Director of Operations, to ensure compliance.

4. QAPI MONITORING.
The facility Director of Operations will perform audits of the facility glass vision panels in corridor walls to assure compliance, monthly for three months and then quarterly for one year and report to the QAPI committee quarterly.

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: Widespread
Severity: Potential to cause minimal harm
Citation date: June 29, 2018
Corrected date: August 20, 2018

Citation Details

2012 NFPA 101: 19.2.8 Illumination of Means of Egress. Means of egress shall be illuminated in accordance with Section 7.8. 2012 NFPA 101: 7.8.1.2.3* Energy-saving sensors, switches, timers, or controllers shall be approved and shall not compromise the continuity of illumination of the means of egress required by 7.8.1.2. Based on observation and staff interview, the facility did not ensure that 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 in that exit discharge lighting was operable by a timer device. This was noted at exit discharge locations around the perimeter of the building. The findings are: On 6/29/18 between 10:00am- 11:00am during the recertification survey, exit discharge lighting units around the perimeter of the building were noted to be operable by a timer device. As a result of this configuration, egress lighting would only turn on when the timer was set. There would be no illumination automatically occurring at all times because the timer is set for only a specific time. In an interview on 6/29/18 at approximately 10:24am, the Director of Operations stated that they would add photocells and address the issue. 2012 NFPA 101: 19.2.8, 7.8.1.2.3 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedJuly 27, 2018

K 281
1. IMMEDIATE CORRECTIVE ACTION TAKEN.
a) Upon identification on 06/29/2018 of non-automatic illumination means of egress, including exit discharge around the perimeter of the building, the facility maintenance staff disconnected the timer device in order to maintain automatic illumination without manual intervention, at all times.
b) A licensed electrical contractor was called in and notified of findings. The licensed electrical contractor ordered parts needed for the installation of an automatic illumination system. On 07/25/2018 the licensed electrical contractor completed the necessary installations to assure compliance.
2. THE FOLLOWING CORRECTIVE ACTIONS WERE IMPLIMENTED TO IDENTIFY OTHER AREAS THAT MAY BE AFFECTED.
a) The facility Director of Operations surveyed the means of egress, including exit discharge around the perimeter of the building to assure that illumination is arranged in compliance.
b) The facility Director of Operations gave in-service training to the maintenance staff and receptionist.
3. THE FOLLOWING MEASURES WERE PUT INTO PLACE TO ASSURE COMPLIANCE.
The facility Director of Operations and Administrator created a policy for automatic illumination means of egress, including exit discharge around the perimeter of the building
The facility Director of Operations will inspect and document the automatic illumination system monthly, and a nightly visual inspection will be performed by the receptionist.
4. QAPI MONITORING.
The facility Director of Operations will perform audits of automatic illumination means of egress, including exit discharge around the perimeter of the building to assure compliance, monthly for three months. Then quarterly for one year and report to the QAPI committee quarterly.

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: June 29, 2018
Corrected date: August 20, 2018

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 were provided in the smoking area on the recreation patio. The findings are: On 6/29/18 at approximately 10:17am during the recertification survey, ashtrays of a safe design with a center rest were not provided in the smoking area on the recreation patio. Multiple smoking outposts were provided in lieu of the required ashtrays. The outposts were not configured to allow a resident to put down their cigarette securely. In an interview on 6/29/18 at approximately 10:17am, the Director of Operations stated that they will get the appropriate ashtrays. 2012 NFPA 101: 19.7.4 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedJuly 27, 2018

K 741
1. IMMEDIATE CORRECTIVE ACTION TAKEN.
Upon identification on 06/29/2018 of the facility ashtrays that are not of a safe design with center rest, the smoking monitors were instructed to pay closer attention to residents who rest their cigarettes in the ashtray bowl to assure that the cigarette doesn?t fall out of the ashtray.
2. THE FOLLOWING CORRECTIVE ACTIONS WERE IMPLIMENTED TO IDENTIFY OTHER AREAS THAT MAY BE AFFECTED.
The facility Director of Operations surveyed all of the facility ashtrays to identify those in need of replacement.
3. THE FOLLOWING MEASURES WERE PUT INTO PLACE TO ASSURE COMPLIANCE.
a) The facility Director of Operations researched on-line for ashtrays of a safe design with a center rest and placed an order.
b) The facility Director of Operations and Administrator reviewed and revised the smoking policy.
c) The facility will replace ashtrays with one of a safe design with center rest by 08/01/2018.
d) The facility Director of Operations gave in-service training to the recreation staff, smoke monitors, maintenance and housekeeping staff.
4. QAPI MONITORING.
The facility Director of Operations will perform audits of the facility ashtrays to assure compliance, monthly for three months and then quarterly for one year and report to the QAPI committee quarterly.

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 29, 2018
Corrected date: August 20, 2018

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: 5.4.1.4* 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: 13.4.2 Check Valves. 2011 NFPA 25: 13.4.2.1 Inspection. Valves shall be inspected internally every 5 years to verify that all components operate correctly, move freely, and are in good condition. Based on observation, staff interview and documentation review, the facility did not ensure that 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 in that: 1) a spare dry type pendent sprinkler head was not maintained on the property; and 2) there was no documentation provided regarding a check valve inspection completed within the last five years. The findings are: On 6/29/18 between 11:00am- 1:30pm during the recertification survey, the following was noted: 1) Dry type sprinklers were observed in the walk in refrigerators and freezer of the lobby level kitchen. The facility lacked a spare dry sprinkler head In an interview on 6/29/18 at approximately 11:30am, the Director of Operations stated that he would order the spare dry heads. 2) There was no documentation provided regarding a check valve inspection completed within the last five years In an interview on 6/29/18 at approximately 12:45pm, the Director of Operations stated that he would call the sprinkler company to check for documentation for the check valve inspection. There was no documentation provided at the time of the onsite inspection. 2012 NFPA 101: 9.7.5 2011 NFPA 25: 5.4.1.4, 5.4.1.4.1, 13.4.2, 13.4.2.1 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedJuly 27, 2018

K 353
1. IMMEDIATE CORRECTIVE ACTION TAKEN.
Upon identification on 06/29/2018 of the facility:
a) Lacking a spare dry sprinkler head.
b) In need of documentation for the five year test on the fire sprinkler check valve.
The facility Director of Operations notified its contracted fire sprinkler company and ordered spare dry sprinkler heads and a test for the fire sprinkler check valve.
On 07/05/2018 spare dry sprinkler heads were delivered to the facility.
A fire sprinkler check valve test was performed and documentation was provided by our contracted fire sprinkler company on 07/05/2018.
2. THE FOLLOWING CORRECTIVE ACTIONS WERE IMPLIMENTED TO IDENTIFY OTHER AREAS THAT MAY BE AFFECTED.
The facility Director of Operations audited the designated fire sprinkler head box to assure heads are available for the fire sprinkler heads utilized in the facility.
3. THE FOLLOWING MEASURES WERE PUT INTO PLACE TO ASSURE COMPLIANCE.
a) The facility Director of Operations and Administrator reviewed and revised the facility policy for fire sprinkler heads and testing of the fire sprinkler system.
b) The facility Director of Operations gave in-service training to the maintenance staff regarding spare sprinkler heads and the five year test for the fire sprinkler check valve.
c) The Facility Director of Operations will check the availability of spare sprinkler heads monthly and as needed and will replace them as it is used.
4. QAPI MONITORING.
The facility Director of Operations will perform audits of the designated fire sprinkler head box to assure compliance, monthly for three months and then quarterly for one year and report to the QAPI committee quarterly.
The fire sprinkler five year check valve test will be reported at the next QAPI 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: June 29, 2018
Corrected date: August 20, 2018

Citation Details

2012 NFPA 101: 19.2.2.3 Stairs. Stairs complying with 7.2.2 shall be permitted. 2012 NFPA 101: 7.2.2.5.1.1 All inside stairs serving as an exit or exit component shall be enclosed in accordance with 7.1.3.2. 2012 NFPA 101: 7.1.3.2 Exits. 2012 NFPA 101: 7.1.3.2.1 Where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following: (1)*The separation shall have a minimum 1-hour fire resistance rating where the exit connects three or fewer stories. (2) The separation specified in 7.1.3.2.1(1), other than an existing separation, shall be supported by construction having not less than a 1-hour fire resistance rating. (3)*The separation shall have a minimum 2-hour fire resistance rating where the exit connects four or more stories, unless one of the following conditions exists: (a) In existing non-high-rise buildings, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating. (b) In existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating. (c) The minimum 1-hour enclosures in accordance with 28.2.2.1.2, 29.2.2.1.2, 30.2.2.1.2, and 31.2.2.1.2 shall be permitted as an alternative to the requirement of 7.1.3.2.1(3). (4) Reserved. (5) The minimum 2-hour fire resistance-rated separation required by 7.1.3.2.1(3) shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having a minimum 2-hour fire resistance rating, unless otherwise permitted by 7.1.3.2.1(7). (6)*Structural elements, or portions thereof, that support exit components and either penetrate into a fire resistance-rated assembly or are installed within a fire resistance-rated wall assembly shall be protected, as a minimum, to the fire resistance rating required by 7.1.3.2.1(1) or (3). (7) In Type III, Type IV, and Type V construction, as defined in NFPA220, Standard on Types of Building Construction (see 8.2.1.2), fire-retardant-treated wood enclosed in noncombustible or limited-combustible materials shall be permitted. (8) Openings in the separation shall be protected by fire door assemblies equipped with door closers complying with 7.2.1.8. (9)*Openings in exit enclosures shall be limited to door assemblies from normally occupied spaces and corridors and door assemblies for egress from the enclosure, unless one of the following conditions exists: (a) Openings in exit passageways in mall buildings as provided in Chapters 36 and 37 shall be permitted. (b) In buildings of Type I or Type II construction, as defined in NFPA 220, Standard on Types of Building Construction (see 8.2.1.2), existing fire protection-rated door assemblies to interstitial spaces shall be permitted, provided that such spaces meet all of the following criteria: i. The space is used solely for distribution of pipes, ducts, and conduits. ii. The space contains no storage. iii. The space is separated from the exit enclosure in accordance with Section 8.3. (c) Existing openings to mechanical equipment spaces protected by approved existing fire protection-rated door assemblies shall be permitted, provided that the following criteria are met: i. The space is used solely for non-fuel-fired mechanical equipment. ii. The space contains no storage of combustible materials. iii. The building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. (10) Penetrations into, and openings through, an exit enclosure assembly shall be limited to the following: (a) Door assemblies permitted by 7.1.3.2.1(9) (b)*Electrical conduit serving the exit enclosure (c) Required exit door openings (d) Ductwork and equipment necessary for independent stair pressurization (e) Water or steam piping necessary for the heating or cooling of the exit enclosure (f) Sprinkler piping (g) Standpipes (h) Existing penetrations protected in accordance with 8.3.5 (i) Penetrations for fire alarm circuits, where the circuits are installed in metal conduit and the penetrations are protected in accordance with 8.3.5 (11) Penetrations or communicating openings shall be prohibited between adjacent exit enclosures. (12) Membrane penetrations shall be permitted on the exit access side of the exit enclosure and shall be protected in accordance with 8.3.5.6. Based on observation and staff interview, unsealed penetrations were noted in exit stairwells. This was noted in two of two exit stairs on five of five floors. The findings are: On 6/29/18 between 8:45am- 1:30pm during the recertification survey, unsealed conduit and wire penetrations were observed above the doors to exit stairs E & F on all five floors. In an interview on 6/29/18 at approximately 9:25am, the Director of Plant Operations stated that he would have the penetrations sealed. 2012 NFPA 101: 19.2.2.3, 7.2.2.5.1.1, 7.1.3.2, 7.1.3.2.1 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedJuly 27, 2018

1. IMMEDIATE CORRECTIVE ACTION TAKEN.
Upon identification on 06/29/2018 of the unsealed penetrations noted in exit stairwells E and F on five of the five floors, the maintenance staff sealed the penetrations with the approved 3M red four hour rated fire barrier sealant on the same day.
2. THE FOLLOWING CORRECTIVE ACTIONS WERE IMPLIMENTED TO IDENTIFY OTHER AREAS THAT MAY BE AFFECTED.
The facility Director of Operations surveyed the other exit stairwells to assure other areas were not affected by the same findings.
3. THE FOLLOWING MEASURES WERE PUT INTO PLACE TO ASSURE COMPLIANCE.
a) The facility Director of Operations and Administrator reviewed and revised the facility policy for penetrations.
b) The facility Director of Operations gave in-service training on penetrations to the maintenance staff.
c) A maintenance log will be maintained by the facility Director of Operations which include dates and reason penetrations occurred and date of sealing.
4. QAPI MONITORING.
The facility Director of Operations will perform audits for unsealed penetrations in all stairwells monthly for three months and then quarterly for one year, for the compliance of fire barriers and report to the QAPI committee quarterly.