Morris Park Rehabilitation and Nursing Center
March 24, 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: March 24, 2017
Corrected date: April 21, 2017

Citation Details

Based on observation it was determined that the facility did not ensure that the fire protection system for the cooking equipment was maintained in accordance with NFPA 96. Reference is made to the piping/nozzle system installed for the fire protection of the stove tops and the griddle system that were not secured tightly so as to prevent accidental movement by hand. The findings include: On 3/20/17 to 3/21/17 at 10:00 AM to 2:00 PM, during the re-certification survey, it was observed that the facility had installed a chemical type fire extinguishing system for protection of the cooking equipment in the kitchen. The piping system with attached nozzles were loosely installed so as to be easily moved by hand. All piping and nozzles installed in connection with the fire protection system for the cooking equipment must be installed and maintained so as not to be moved by hand from their proper location, as per NFPA 96. On 3/21/17 at approximately 11:00 AM, the facility Director of Maintenance stated that the fire suppression equipment company will be contacted to secure the fire extinguishment system piping and nozzles so as not to be moved by hand from their actual location. 10NYCRR 711.2(a) 2012 NFPA101 2011 NFPA 96

Plan of Correction: ApprovedApril 21, 2017

K324:
The Wet Chemical Fire Suppression system piping and attached nozzles installed over the kitchen cooking equipment that were identified as loosely installed were tightened in place by the facility vendor. The nozzles were affixed permanently over the cooking equipment as required on 03/20/2017.
The facilities vendor inspected all piping and nozzles of the Wet Chemical Fire Suppression system and ensured the entire system was properly tight and the nozzles were affixed permanently over the cooking equipment as required on 03/20/2017.
The Preventive Maintenance & Scheduling program will be followed reflecting the monthly and semi-annual inspection of Wet Chemical Fire Suppression system and will be documented in the Facilities Records & Logs.
The Director of Maintenance has been assigned the responsibility for monitoring the Wet Chemical Fire Suppression system and report the findings to the Safety Committee regularly.
The Maintenance Director will report the result of these audits to the Safety committee on a monthly basis, as well as correction plan if warranted.

K307 NFPA 101:EGRESS DOORS

REGULATION: Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 24, 2017
Corrected date: April 21, 2017

Citation Details

Based on observation it was determined that the facility did not ensure that the doors equipped with the delayed-egress system would be released in accordance with the posted instructions. Reference is made to the exit discharge door from the North exit stairs that was equipped with a delayed-egress system that could not be opened when pushed by the facility Director of Maintenance. The findings include: On 3/20/17 to 3/21/17 at 10:00 AM to 2:30 PM, it was observed that facility had installed a delayed-egress system at the exit discharge door from the North stairs. The door could not be released when pushed by the facility's Director of Maintenance, as per posted instructions. The door releasing mechanism was not initiated when pushed at the panic bar type door releasing device for the specified time period. On 3/21/17 at approximately 12:45 PM, the facility's Director of Maintenance stated that the door vendor will adjust the delayed-egress mechanism so as to open when pushed as per posted instructions. 10NYCRR 711.2(a) 2012 NFPA 101 - 19.2.2.2.5.1, 7.2.1.6.1.1

Plan of Correction: ApprovedApril 21, 2017

K222:
The Exit discharge door from the North Stairs is equipped with a delayed egress door that did not open within 15 seconds as posted. The facilities vendor adjusted the delayed egress mechanism to open within 15 seconds on (MONTH) 21, (YEAR).
On (MONTH) 21, (YEAR) facility Maintenance Director conducted an inspection of all delayed egress doors for compliance throughout the facility. All delayed egress doors were in compliance.
The Preventive Maintenance & Scheduling program will be followed reflecting inspection of Delayed Egress Doors and will be documented in the Facilities Records & Logs.
The Maintenance Director has been assigned the responsibility for monitoring the Delayed Egress mechanisms and report the findings monthly to the Safety Committee regularly.

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 24, 2017
Corrected date: April 21, 2017

Citation Details

Based on observation it was determined that the facility did not ensure that all exit access corridors/passageways were maintained free of storage that would interfere with their safe use during fire or other emergency. Reference is made to the stored cartoned supplies in the passageway leading to the exit ramp to the street on the lobby level. The findings include: On 3/20/17 at 10:00 AM to 2:30 PM during the re-certification survey, it was observed that the facility had stored cartons of supplies in the exit passageway leading to the exit ramp to the street on the lobby floor. Such storage in an exit passageway would make the passageway impassable during fire or other emergency. All means of egress are to be maintained free of any storage that would interfere with their safe use by the building occupants. On 3/21/12, at 12:15 PM, the facility Director of Maintenance stated that the stored items in the exit passageway were being removed and that the staff had been instructed to maintain the passageway clear of any storage. 10NYCRR 711.2(a) 2012 NFPA 101

Plan of Correction: ApprovedApril 21, 2017

K211:
On (MONTH) 20, (YEAR) Facility Engineering staff removed all cartons (boxes) supplies that were stored in the exit passageway leading to exit ramp to the street on the lobby floor.
On (MONTH) 20, (YEAR) facility engineering staff conducted inspection of all exit access corridors leading to exits throughout the facility and checked for storage in the corridor. No further storage was found.
The Maintenance Director or designee as part of the daily environmental rounds will begin conducting audits to ensure no items are stored along exit access corridor leading to exits. Documentation Attached.
Facility Engineering and Environmental Services staff will be re-educated on the requirements that all access corridors/passageways are continuously maintained free of all obstructions to full use in case of emergency. All participants will understand the life safety issues identified during the facility?s survey and the importance of ensuring compliance with the identified life safety issues on a routine basis. In-service Attendance Sheet Attached.
The Maintenance Director will report the result of these audits to the Safety committee on a monthly basis, as well as correction plan if warranted.

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: March 24, 2017
Corrected date: May 17, 2017

Citation Details

2010 NFPA 13 Standard for the Installation of Sprinkler Systems Section 6.7.4* Identification of Valves. 6.7.4.1 All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. 6.7.4.2 The identification sign shall be secured with corrosion-resistant wire, chain, or other approved means. 6.7.4.3 The control valve sign shall identify the protion of the building served. Based on observation, it was determined that the facility did not ensure that all areas in the building were protected by an approved automatic sprinkler system in accordance with Section 9.7 and NFPA 13. Reference is made to the lack of an approved fire extinguishing system in the elevator machine room and lack of an identification sign for the number of sprinkler control valves in the sprinkler room and the maintenance room. The findings include: On 3/20/17 to 3/21/17 at 10:00 AM to 3:00 PM during the re-certification survey, the following was observed: (1) The facility had installed the chemical type fire extinguishing system in the elevator machine room. The extinguishing system consisted of wall mounted portable type fire extinguisher with standard sprinkler heads affixed on their tops. Although this extinguishing system appeared to be connected to the facility fire alarm system, two out of four portable type fire extinguishers lacked a connection to the facility's fire alarm system. The facility had no documentation to show that the installed fire extinguishing system was an approved system. Any alternative extinguishing system other than the standard water based sprinkler system must be approved by the New York City Department of Buildings (NYCDOB) and New York City Fire Department (FDNY). (2) A number of sprinkler control valves located in the sprinkler control room lacked appropriate identification signs. Also, the identification signs installed for the sprinkler control valves located in the maintenance shop and the 6th floor lacked information with regards to the section of the system controlled by these valves. All control valves, test connection valves, and drain valves must be identified with metal or rigid plastic identification signs secured with corrosion resistant wire, chain or other approved means. On 3/21/17 at approximately 11:30am the facility's Director of Maintenance stated that the sprinkler company will be contacted to provide documentation with regards to the approval of extinguishing system installed in the elevator machine room. The Director also stated that all sprinkler control valves will be provided with appropriate identification signs as per NFPA 13. 10NYCRR 711.2(a) 2012 NFPA 101 -9.7 2010 NFPA 13 - 6.7.4

Plan of Correction: ApprovedApril 21, 2017

K351 (1):
The Elevator machine room has a Dry Chemical Automatic Extinguishing system installed that is connected to the Building fire alarm system. It has been determined the vendor did not obtain approval from the FDNY or the Department of Buildings.
As of 4/21/17 the facility has contacted approved fire suppression vendors and requested proposals to install an automatic fire suppression system that could be connected to the fire alarm system and approved by the authority having jurisdiction.
The Vendor will initiate the permit process with the FDNY for the installation of the automatic fire suppression system. The installation of the automatic fire suppression system will immediately follow. The scope of the work is approximately one week.
The facility Fire Alarm Company will connect the new system to the fire alarm system. The scope of work is approximately two weeks.
Upon completion of the installation of the new system connected to the fire alarm system, the approved vendor will inspect and test the system as designed. A licensed P.E. or Architect will certify the system was installed as designed and meets NFPA 13 requirements and all applicable codes, rules, and regulations. Vendor will order an inspection from the authority having jurisdiction, FDNY for approval.
Based on the scope of the work to install the automatic fire suppression system in elevator machine room, connect it to the Fire Alarm System and obtain approval from the authority having jurisdiction (FDNY), the facility is applying for a Time Limited Waiver.
The automatic fire suppression system will continue to be inspected and tested in accordance with all applicable codes, rules, and regulations by authorized vendors and the Director of Maintenance.
The Director of Maintenance will report audit findings to the Safety Committee on a monthly basis until the automatic fire suppression system installation is completed and approved. Following the completion of all inspections, testing, and approvals the Safety Committee will make a decision regarding the need to continue auditing this issue.
The automatic fire suppression system will continue to be inspected and tested in accordance with all applicable codes and recorded in the facility Records & Logs.
K351 (2):
The sprinkler control valve identification signs identified in the Maintenance Room, the sprinkler control room, and the 6th Floor were permanently replaced with metal and/or rigid plastic signs that indicated the section the control valve controls.
The Maintenance Director conducted an inspection of all sprinkler control valves throughout the facility to ensure all signage was in compliance. All signage is in compliance.
The Preventive Maintenance & Scheduling program will be followed reflecting the monthly, quarterly and annual inspection of Automatic Sprinkler system and will be documented in the Facilities Records & Logs.
The Director of Maintenance has been assigned the responsibility for monitoring the Automatic Sprinkler system and report the findings to the Safety Committee regularly.

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: March 24, 2017
Corrected date: April 21, 2017

Citation Details

Section: 7.2.2.2.4.1 states that means of egress that are more than 30 inches (26cm) above the floor or grade below shall be provided with guards to prevent falls over the open side. This standard is not met as evidence 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 not less than 42 inches high as per 7.2.2.4.5. Reference is made to the guards provided at the open side of the top landings in the north and south exit stairs that were 30 inches and 39 inches high instead of the minimum of 42 inches high from the landings' floors. The findings include: On 3/20/17 to 3/21/17 at 10:00 AM to 2:30 PM it was observed that the facility had provided guard rails at the open side of the top landings within the north and south exit stairs. The guards on the stair landings measured approximately 30 inches from the floor in the north exit stair and 39 inches in the south exit stair. The guards installed at the open side of the landings must be at least 42 inches high from the adjacent surface (landing). On 3/21/17 at approximately 12:00 PM, the facility's Director of Maintenance stated that the guard rails will be extended to the required height. 10NYCRR 711.2(a) 2012 NFPA 101 - 7.2.2.2.4.1

Plan of Correction: ApprovedApril 21, 2017

K225:
The guard rails measuring 30 inches and 39 inches at the open side of the top landings within exit stair north and south exit stairs will be permanently raised to 42 inches high from the adjacent surface (landing). Work has been completed by (MONTH) 20th (YEAR).
The Maintenance Director inspected all guard rails at the open side of top landing at all stairs to ensure rails at least 42 inches high from the adjacent surface. The north and south exit stairs are permanently raised to 42 inches high from the adjacent surface (landing).
The north and south exit stairs are permanently raised to 42 inches high from the adjacent surface (landing).

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: March 24, 2017
Corrected date: May 17, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Physical Plant Violations-State Only 713-2.21 Mechanical systems and equipment requirements (d) Heating and ventilating systems shall comply with the following: (2)(ii)The ventilation systems shall be designed and balanced to provide the pressure relationship as shown in Table 8. This requirement is not met as evidence by: Based on observation and staff interview it was determined that the facility did not ensure that the ventilation system for the building was designed and maintained to provide ventilation and balanced to provide the pressure relationship to the adjacent areas as per 713-2.21(d). Reference is made to the lack of exhaust ventilation system in the toilet room off of room [ROOM NUMBER], and the non-functional air handling equipment serving resident corridors. The findings include: On 3/20/17 and 3/21/17 at 10:00 AM to 2:30 PM, the following was observed during the re-certification survey of the facility: (1) The toilet room off resident room [ROOM NUMBER] lacked an exhaust ventilation system. The resident toilet rooms must be provided with a ventilation system to create a negative pressure relationship to the adjacent area with a minimum of 10 total air changes per hour to the toilet room. (2) The air supply grilles provided in the resident corridors were noted to be closed off. Interview with the facility Director of Maintenance revealed that the ventilation grilles were not needed because of the two air handling equipment units installed on the roof that were designed to provide outdoor air ventilation. The system was out of order for an unknown period of time and the Director further stated that the grilles were closed off to prevent unnecessary openings in the corridors. The resident corridors must be provided with a minimum of two outdoor air changes per hour and balanced to provide an equal pressure relationship with the adjacent area. On 3/21/17 at approximately 12:30 PM, the facility Director of Maintenance stated that the HVAC (heating, ventilation and air conditioning) company will be contacted to evaluate and provide proper ventilation systems for the resident corridors and the toilet rooms. 713-2.22 Electrical requirements (h) Emergency electrical services shall comply with the following: (3) Emergency electric service shall be provided to the distribution system as follows: (viii) General illumination and selected receptacles in the vicinity of the generator set. This requirement is not met as evidence: Based on observation it was determined that the facility did not ensure that the emergency generator set location was provided with emergency battery-powered lighting as per NRPA 99. The findings include: On 3/20/17 and 3/21/17 at 10:00 AM to 2:30 PM it was observed that the facility has provided an onsite emergency power generating set. The generator is installed in an outside enclosure. At approximately 1:00 PM on 3/21/17, it was noted that an emergency battery powered lighting unit with battery charger was lacking within the enclosure. The facility Director of Maintenance stated that the generator company will be contacted to install a battery-powered lighting unit within the generator set enclosure as per NFPA 99. 415.29 2012 NFPA 99

Plan of Correction: ApprovedApril 21, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I560 713-2.21 Mechanical systems:
1) The identified Resident Bathroom [ROOM NUMBER] lacked an exhaust ventilation system. A new mechanical exhaust was permanently installed in the identified bathroom that provides a negative air pressure in relationship to the adjacent area with a minimum of 10 total air changes per hour to the toilet room.
2) The facility HVAC contractor was engaged to repair the two identified air handling equipment units. The units will provide a minimum two outdoor air exchanges per hour and balanced to provide an equal pressure relationship with the adjacent area.
The Maintenance Director conducted an inspection of all bathrooms to verify each was permanently provided with an operational mechanical exhaust unit. An inspection of all HVAC units was also completed to verify all systems were operational.
The Preventive Maintenance & Scheduling program will be followed reflecting inspections and maintenance of the building HVAC systems and will be documented.
The Director of Maintenance has been assigned the responsibility for monitoring the HVAC system and report the findings to the Safety Committee regularly.
I560 713-2.22 Electrical requirements:
The Facilities onsite Emergency Generator is installed in an outside enclosure. The Emergency Generator set location was not provided with emergency battery-powered lighting. The facility contacted a vendor and an emergency battery-powered light with charger will be installed.
The Maintenance Director conducted an inspection of Generator set locations and transfer switches. All were provided permanently with emergency battery-powered lighting.
The Preventive Maintenance & Scheduling program will be followed reflecting monthly and annual inspections and maintenance of the emergency battery-powered lights and will be documented in the Facilities Records & Logs.
The Director of Maintenance has been assigned the responsibility for monitoring the emergency battery-powered lights and report the findings to the Safety Committee regularly.