New Carlton Rehab and Nursing Center, LLC
June 23, 2017 Certification Survey

Standard Health Citations

BEDROOMS MEASURE AT LEAST 80 SQ FT/RESIDENT

REGULATION: (e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms;

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: 2017-06-23
Corrected date: 0000-00-00

Citation Details

Details not available

Plan of Correction: N/A

Plan of correction not approved or not required

FF10 483.10(i)(2):HOUSEKEEPING & MAINTENANCE SERVICES

REGULATION: (i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 23, 2017
Corrected date: August 11, 2017

Citation Details

Based on observation and interview during the Recertification Survey, the facility did not ensure that housekeeping and maintenance services were provided necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, including but not limited to; bedside furniture, suction machines, Hoyer lifts; blood pressure stand, base boards, walls, floors, windows and screens and air conditioner covers were observed heavily soiled and in disrepair. The stairwells between 2 and 3 floors and stairwells between 3 and 4 floors windows and window screens heavily soiled. This was evident during Environmental Observations. (Units 1, 3 and 4). The findings are: During multiple environmental observations conducted on 06/20/17 - 06/23/17 the following was observed: 1.) The windows, window screens and window sills between stairwells 2 and 3 and 3 and 4 were heavily soiled, with black soot dirt and debris. 2.) The suction machines located on the 1st and 3rd floors were accumulated with dust and dirt. The suction machine tables were in disrepair with cracked or missing corners. 3.) The Hoyer lift located on the 3rd floors was heavily layered with dirt, dust and rust stains. The padding hanging on the shoulder strap area was heavily soiled and stained. The weight scale was accumulated with dirt and dust. The walls were covered with old and used tape that had not been removed. The blood pressure stand was layered with dirt and dust. 4.) The floors in units 3 and 4 were heavily soiled, with ground in dirt and black soot pushed into the corners and edges all along the corridors. The base boards were peeled and covered with black soot and dirt. 5.) The air conditioners in rooms room 312 had paper stuffed underneath the bottom half of the frame. The air conditioner cover was missing. 6.) The air conditioner in room 412 had foam covering which was torn, dirty and in poor condition. 7.) The bedside furniture tables in room 410 A was observed peeling and in disrepair. 8.) The base of the hand sinks at the nurse station was encrusted with dirt and black substance. The following was observed in the Rehabilitation area: 9.) The parallel bars was cluttered with four (4) large boxes containing shoes. 10.) The chair to the stationary bike was stained and streaked. 11.) The hand roll machine was encrusted with dirt and debris. 12.) The large floor mirror was heavily stained and streaked. The shelf at the base of the mirror was cluttered with weight bands. The Director of the Rehabilitation Department (DOR) interviewed on 06/22/17 at 10:15 am and he stated that his staff are responsible for cleaning all equipment and maintaining the equipment that is used by the residents. The DOR stated that the boxes containing shoes were placed inbetween the parallel bars because of lack of space and are removed when the parallel bars are to be used. The Director of Housekeeping (DOH) was interviewed on 06/23/17 at 11: 15 am and stated that he is responsible for keeping the building clean and safe. The DOH stated that he checks up on his staff right by going through the building and on the units and checks up on their assigned work. The DOH stated that the building is old and needs a lot of work. The DOH stated that a general cleaning for each room is done daily. The general cleaning includes the cleaning down of the beds, frames, walls, floors. The DOH stated that routine daily cleaning is done every day and includes sweeping, mopping, garbage removal of units and floors. The Assistant Director of Maintenance (ADoM) was interviewed on 06/23/17 at 12: 30 PM and stated that he makes rounds bi-weekly of units and checks for safety concerns and / or needed repairs. The ADoM stated that he is notified verbally or by phone when there is a need or there is problem for him to fix. The ADoM stated that he recently repaired the base boards and when he make rounds he will repair this. 415.5(h)(3)

Plan of Correction: ApprovedAugust 1, 2017

Element #1 - All items listed as findings were discussed with housekeeping and maintenance department. Windows, window screens and sills on stairwell were immediately cleaned.
The suction machine on the 1st and 3rd floor was immediately cleaned, and new suction machine tables were ordered.
The Hoyer lift on the 3rd floor was immediately cleaned. The Hoyer pads were immediately washed. The blood pressure machine was thoroughly cleaned. The weight scales were immediately cleaned. Rounds are being made throughout building to remove old tape from walls.
New baseboards are being ordered for all common areas in the building and will be installed as soon as they arrive.
Floors in question were immediately cleaned and buffed.
Air conditioners in room 312 and 412 were examined. One was cleaned and one was replaced.
New bedside tables have been ordered and will be installed as soon as they arrive.
Base of sinks has been examined and cleaned/repaired.
Items blocking access to parallel bars have been removed.
New stationary bike has been ordered.
Hand roll machine has been cleaned.
Floor mirror and surrounding area were cleaned and organized.
Element #2 - All areas of building may be subject to this deficient practice.
Element #3- One additional full time housekeeping worker has been hired. A staff meeting/In-Service occurred on 6/26 and 6/27. Housekeeping policies and procedures were reviewed. It was determined that the housekeeping department has not been following the established policies and procedures. A housekeeping audit checklist will be formulated and the lead porter will fill out this audit; two rooms on each floor per week, as well as common areas on all floors, for a period of four weeks, and then one floor per week for the next eight weeks. At the In-Service, the policies and procedures for maintenance were reviewed and the following adjustment was made: one maintenance worker will be responsible for all wall care. The other maintenance worker will be responsible for routine maintenance and the submitting of a preventative maintenance audit. This audit sheet will be completed for one floor per day for four weeks and then will be completed for one floor per week for eight weeks. On 6/27 an In-Service was held with the Director of Rehabilitation to review policies and procedures relative to cleanliness and the cleaning and disinfecting of resident care equipment. Policy and procedure has been updated so that each individual rehabilitation worker is responsible for the cleaning and disinfecting of equipment used in between each resident. Rehabilitation will submit to the administrator weekly, for three months an audit checklist verifying compliance with this plan of correction.
Element#4-The Administrator is ultimately responsible for monitoring the audits provided by maintenance and housekeeping and rehabilitation. The administrator will bring all audits mentioned in Element 3 to the quarterly QAPI meeting. In addition, there is a daily department heads meeting; any issues that are found to indicate the non compliance with the P(NAME) will be addressed daily. In addition, Administrator will make daily rounds on at least one floor per week, for three months to verify compliance with the P(NAME). Employees will be counseled and/or disciplined if the rounds reveal a failure to follow policies and procedures pertaining to housekeeping and/or maintenance.

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: Pattern
Severity: Potential to cause minimal harm
Citation date: September 19, 2017
Corrected date: N/A

Citation Details

The following waiver is on file with this office. Repeat waiver is granted based on previous justification by the owner, previous NYSDOH and USDHHS reviews and certification that the condition under which the waiver has been granted has not changed. Please indicate if the facility wishes the waiver to be continued or provide a plan of correction. LSC 13-3.6.1 K362 S/S=B Resident dining rooms/dayrooms on floors 2 through 4 are not separated from corridors by 1 hour fire resistive construction. Reference is made to unsealed corridor and resident room walls on the floors referenced above. NYCRR 711.2(a)(1)The following waiver is on file with this office. Repeat waiver is granted based on previous justification by the owner, previous NYSDOH and USDHHS reviews and certification that the condition under which the waiver has been granted has not changed. Please indicate if the facility wishes the waiver to be continued or provide a plan of correction. LSC 13-3.6.1 K362 S/S=B Resident dining rooms/dayrooms on floors 2 through 4 are not separated from corridors by 1 hour fire resistive construction. Reference is made to unsealed corridor and resident room walls on the floors referenced above. NYCRR 711.2(a)(1)

Plan of Correction: ApprovedOctober 4, 2017

PLEASE CONTINUE WAIVER

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: Widespread
Severity: Potential to cause more than minimal harm
Citation date: June 23, 2017
Corrected date: September 5, 2017

Citation Details

Based on observation, staff interview and record review, it was determined that the facility did not ensure that all electrical equipment used in the patient care rooms was maintained and tested in accordance with NFPA 99. Reference is made to the lack of documentation to show that the resident use electric beds and feeding pumps provided in resident rooms (room #'s 14, 411, 302) were maintained and tested for safety, as per manufacturer instructions and/or as per policies and protocols established by the facility. The findings include: On (MONTH) 20, (YEAR) at 10:00 AM to 3:30 PM, during the annual recertification survey, it was observed that the facility had provided Invacare made electric beds, Covidien made feeding pumps and Kangaroo made feeding pumps in resident rooms (room #'s 14, 411, 302). An interview with the facility's Director of Maintenance and review of the facility's maintenance records revealed that the facility lacked documentation to show that the resident electric beds and feeding pumps were maintained and tested in accordance with established policies and protocols. Also, the facility had not retained any maintenance and care manuals by the manufacturer for the electrical equipment, and had not established any policies and protocols for the maintenance and type of tests and intervals of testing for the residents' electric use electrical equipment. On (MONTH) 20, (YEAR), at approximately 12:30 PM, the facility's Director of Maintenance stated that the manufacturers of residents' electric beds and electric feeding pumps will be contacted to provide care manuals for all electrical equipment. The Director further stated that policies and protocols for maintenance and testing of resident use electrical equipment based on manufacturers' recommendations will be established and followed and records maintained as per NFPA 99. 711.2 (a)(1) 2012 NFPA 101 2012 NFPA 99

Plan of Correction: ApprovedOctober 4, 2017

Element #1 - Maintenance has requested manuals for electric beds, feeding pumps - both Kangaroo and Coviden. The checking of this equipment, as per manufacturer specifications, will be added to preventative maintenance checklist.
Element #2 - All electrical equipment is subject to this deficient practice.
Element #3 - An In-service was held with maintenance department regarding the requirement to maintain electrical equipment used for patient care as per manufacturer specifications. The checking of these items has been added to the preventative maintenance checklist. This audit will be done one floor per day for 8 weeks and will then revert to minimally one floor per week.
Element #4 - Administrator is responsible for checking preventative maintenance rounds checklist to ensure compliance with plan of correction.

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: June 23, 2017
Corrected date: August 1, 2017

Citation Details

Based on observation, it was determined that the facility did not ensure that doors protecting openings to hazardous areas enclosures were provided with appropriate latching mechanism. Reference is made to the doors to the storage room/file cabinets storage area that lacked a latching mechanism. The findings include: On (MONTH) 20, (YEAR) at 10:00 AM to 3:30 PM, it was observed that the facility's hazardous areas were protected with an automatic fire extinguishing system. However, the two doors to the storage room/file cabinets storage room on the first floor lacked a latching mechanism. On (MONTH) 20, (YEAR) at approximately 12:45 PM, the facility's Director of Maintenance Services stated that the doors to the file cabinets storage room on the first floor will be provided with an appropriate latching mechanism. 711.2 (a)(1) 2012 NFPA 101

Plan of Correction: ApprovedOctober 4, 2017

Element #1 - Doors to the area in question have been provided with automatic latching mechanisms.
Element #2 - All doors are potentially subject to this deficient practice.
Element #3 - Doors to the area in question will be provided with automatic latching mechanisms. Checking that all self closing doors are latching properly will be added to preventative maintenance checklist. An In-service was provided by the Administrator to the Maintenance Department regarding the use of and rationale for preventative maintenance checklist. For eight weeks the maintenance department will conduct preventative maintenance , one floor per day. After eight weeks, these audits will continue minimally one floor per week. All audits will be provided each Friday to the Administrator. Items will be corrected as ascertained during these audits.
Element #4 - The Administrator is responsible for reviewing these audits and presenting the findings to the QAPI Committee. The Administrator will do random audits at least one floor per week for eight weeks, to validate compliance with plan of correction.

K307 NFPA 101:PORTABLE FIRE EXTINGUISHERS

REGULATION: Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 23, 2017
Corrected date: August 2, 2017

Citation Details

Based on observation and review of facility maintenance records, it was determined that the facility did not ensure that portable chemical type fire extinguishers were hydrostatically tested in accordance with NFPA 10, Standard for Portable Fire Extinguishers. Reference is made to the chemical type fire extinguisher provided on the 4th floor that lacked the hydrostatic test record (tag). The findings include: On (MONTH) 20, (YEAR) at 10:00 AM to 3:30 PM, it was observed that the facility had provided Badger make portable chemical type fire extinguishers on the resident floors. The chemical type portable fire extinguisher on the 4th floor, with the manufacturing date of 2003, was not subjected to the required twelve year hydrostatic test. The fire extinguisher lacked the hydrostatic test tag since 2003. On (MONTH) 20, (YEAR) at approximately 12:15 PM, the facility's Director of Maintenance stated that the extinguisher company will be contacted to replace all chemical extinguishers that are not hydrostatically tested every twelve years as per NFPA 10. 711.2 (a)(1) 2012 NFPA 101 2010 NFPA 10

Plan of Correction: ApprovedOctober 4, 2017

Element #1 - Our fire extinguisher company has been contacted to come to facility and review the fire extinguisher on the 4th floor. Testing was done 2013, not 2003, as cited on this inspection report.
Element #2 - All portable fire extinguishers are subject to this deficient practice.
Element #3 - All extinguishers have been inspected and tested within mandated testing parameters for either hydrostatic or Co2 extinguishers.
Element #4 - Fire extinguisher company presents to administrator their report of monthly inspection of fire extinguishers. Any issues ascertained will be corrected during the monthly inspection. Administrator will review findings to ensure compliance with plan of correction and present findings to QAPI Committee.

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: June 23, 2017
Corrected date: September 19, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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. Reference is made to the lack of sprinkler coverage for a number of areas in the building. Examples include: the elevator machine room lacked an automatic extinguishing system; a large storage shed located on the roof; the female residents' central shower area on the 4th floor; lack of sprinkler within six feet of the wall adjacent to room [ROOM NUMBER]/407, 311 and 315; the dressing area and shower stall within central shower area on the 3rd floor; obstructed sprinkler in the 3rd floor male residents' central shower area; the use space under a large overhang/low ceiling in room [ROOM NUMBER]; obstructed sprinklers in the central toilet area on the 2nd floor; ceiling pockets greater than 36 inches lack sprinklers in room [ROOM NUMBER], 208, 211; lack of sprinklers within six feet from the wall in the smoking room; lack of sprinklers in the vestibule to 1st floor toilet room; section of hood system in the kitchen lacks sprinklers; large vestibule area in the standpipe valve room lacked sprinklers; section of boiler room area lacked sprinklers; the use area under greater than 4 feet wide overhang within kitchen tray set up area lacked sprinklers; use area under greater than 4 feet wide mechanical unit in the rehabilitation section lacked sprinklers. The findings include: On (MONTH) 20, (YEAR) at 10:00 AM to 3:30 PM, it was observed that a number of areas in the building, including but not limited to the following, lacked sprinklers, or the existing sprinklers were obstructed so as not to provide coverage for the entire protected area: (1) The elevator machine room lacked an automatic fire extinguishing system. (2) A storage shed on the room, measuring approximately 15 feet x 10 feet, storing cartons and furniture, lacked sprinklers. (3) In the 4th floor female residents' central toilets/shower area, the recessed area containing the handwashing sink and the shower area adjacent to toilet stall lacked automatic sprinklers. (4) Automatic sprinklers were not provided within 6 feet of the walls in the corridors adjacent to room [ROOM NUMBER]/407 room [ROOM NUMBER], room [ROOM NUMBER]/309; corridor leading to room [ROOM NUMBER], within room [ROOM NUMBER], 214 and room [ROOM NUMBER]; and the corridor leading to stair B, on the 3rd floor. The sprinklers were located at a distance of 8 feet to 11 feet from the walls. (5) The sprinkler valve identification signs lacked information with regard to the section of the system these valves control. Examples were: the sprinkler valves in the vicinity of the elevator on the 4th floor and the valves across from room [ROOM NUMBER]. (6) In the central shower/toilet area on the 4th floor, the sprinklers were obstructed by the high soffit or walls/ partitions so as not to provide coverage for the dressing area and the shower stall. (7) On the 3rd floor, in the central shower/toilets for the female residents, the sprinklers were obstructed by the solid type of curtains so as not to provide coverage for the entire protected area. (8) In room [ROOM NUMBER], sprinklers were not provided under the large (12 ft x 6 ft) overhang/low ceiling. The existing sprinkler was obstructed by an approximately 3 feet high soffit so as not to provided coverage under the overhang. (9) The greater than 3 feet deep ceiling pockets in a number of resident rooms lacked automatic sprinklers. Examples were: room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER] and the corridor adjacent to room [ROOM NUMBER] and 211. The existing sprinklers were obstructed by approximately 7 feet high soffits so as not to provide coverage for the resident bed areas located under the ceiling pockets. (10) On the first floor a section of the toilet room located in the administrative area lacked sprinklers. (11) The kitchen section of hood system containing the Garland cooker lacked sprinklers. (12) In the kitchen, a large area behind the exhaust hood system lacked sprinklers. (13) The large vestibule area (6 ft x 10 ft) leading to the standpipe valve adjacent to the kitchen area, lacked sprinklers. (14) The vestibule area to the boiler room and the deep ceiling pocket at the rear section of the boiler room lacked sprinklers. (15 ) In the tray set up area adjacent to kitchen area, automatic sprinklers were lacking under the approximately 6 feet wide overhang. ( 16) In the rehabilitation area, automatic sprinklers were lacking under the approximately 4-1/2 feet wide ceiling mounter motorized mechanical air conditioning unit. (17) The large vestibule area leading to the tray set-up area lacked sprinklers (18) The storage closet off the dietary office in the basement lacked automatic sprinklers. On (MONTH) 20, (YEAR) at approximately 2:00 PM, the facility's Director of Maintenance stated that the sprinkler company will be contacted to evaluate and provide sprinklers in all areas of the building. 711. 2 (a)(1) 2012 NFPA 101 2012 NFPA 13

Plan of Correction: ApprovedOctober 4, 2017

Element #1 - The Administrator immediately contacted the contractor who did the sprinkler installation to survey building regarding the cited location for additional fire sprinklers.
Element #2 - The entire building is subject to this deficient practice.
Element #3 - The contractor has assured us that all areas cited will have sprinklers installed as per statement of deficiencies.
Element #4 - Our sprinkler monitoring company will do bi-annual review of all sprinklers to ensure compliance with plan of correction. Administrator will be responsible to provide audit results at Quarterly QAPI Meeting.

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 23, 2017
Corrected date: September 19, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, it was determined that the facility did not ensure that the sprinklers and sprinkler piping were maintained in accordance with NFPA 13 and NFPA 25. Reference is made to the lack of supporting hangers for the excessive length of the armover/branch line section of sprinkler piping in room [ROOM NUMBER], in the stairway B landing on the 2nd floor; in the dishwashing room; and in the rehabilitation room and female locker room, both in the basement. The findings include: On (MONTH) 20, (YEAR) between 10:00 AM to 3:30 PM, during the re-certification survey of the facility, it was observed that supporting hangers were lacking for the greater than two feet long end of the armover section of the sprinkler piping from the last sprinkler to the last hanger, as per 4-14.2.3.2 and 4-14.2.3.4, NFPA 13, in a number of areas of the facility. Examples were: in room [ROOM NUMBER], in stairway B landing on the 2nd floor; and in the following basement areas: the dishwashing area; the standpipe valve room; the rehabilitation room; and the female locker room. The length of the armover without supporting hanger from the last sprinkler to the last hanger was approximately 3 feet to 6 feet. On (MONTH) 20,2017 at approximately 2:30 PM,the facility's Director of Maintenance stated that the Sprinkler Company will be contacted to install hangers for the excessive length of sprinkler piping, in accordance with NFPA 13. 711.2 (a)(1) 2012 NFPA 101 2012 NFPA 13 1998 NFPA 25

Plan of Correction: ApprovedOctober 4, 2017

Element #1 - The facility has contacted the sprinkler company that conduct the monthly sprinkler tests. The violations cited will be shared with this company and the issues will be added to the bi-annual sprinkler check this company conducts.
Element #2 - The entire sprinkler and standpipe system is subject to this deficient practice.
Element #3 - The sprinkler company will ensure, during the bi-annual sprinkler testing, that the sprinkler and sprinkler piping are maintained in accordance with NFPA 13 AND NFPA 25.
Element #4 - The Administrator will review the report cited in Element 3 and present the findings to the QAPI Committee at the next quarterly meeting. The Administrator will be responsible for ensuring that any items found to be out of compliance in the report mentioned above are corrected.

K307 NFPA 101:SPRINKLER SYSTEM - SUPERVISORY SIGNALS

REGULATION: Sprinkler System - Supervisory Signals Automatic sprinkler system supervisory attachments are installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and provide a signal that sounds and is displayed at a continuously attended location or approved remote facility when sprinkler operation is impaired. 9.7.2.1, NFPA 72

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 23, 2017
Corrected date: September 19, 2017

Citation Details

Based on observation, it was determined that the facility did not ensure that all sprinkler control valves were provided with electrical supervisory attachments in accordance with NFPA 72. Reference is made to the sprinkler control valve located across from the elevators on the 4th floor that lacked the electrical supervisory system attachment. The findings include: On (MONTH) 20, (YEAR) at 10:00 AM to 3:30 PM,during the annual recertification survey of the facility, it was observed that the sprinkler control valve located across from the elevators on the 4th floor, lacked the electrical supervisory system. All sprinkler control valves are to be equipped with an electrical supervisory system so that at least a local alarm will sound and displayed at a continuously attended location when the valve(s) are close. On (MONTH) 20,2017 at approximately 2:15 PM, the facility's Director of Maintenance stated that the sprinkler company will be contacted to evaluate and provide electrical supervisory attachments for all sprinkler control valves in the facility as per NFPA 72. 711.2 (a)(1) 2012 NFPA 101 2010 NFPA 72.

Plan of Correction: ApprovedOctober 4, 2017

Element #1 - The electrical company that services the sprinkler system was contacted to come to facility and correct this issue.
Element #2 - All sprinkler control valves are potentially subject to this deficient practice.
Element #3 - The checking for electrical supervisory attachments will be added to the bi-annual sprinkler inspection audit that the sprinkler monitoring company conducts and this report will be presented to the Administrator.
Element #4 - The Administrator will review the report cited in Element 3 and present the findings to the QAPI Committee at the next quarterly meeting. The Administrator will be responsible for ensuring that any items found to be out of compliance in the report mentioned above are corrected.

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 23, 2017
Corrected date: August 3, 2017

Citation Details

I. Section 7.1.8, states that guards in accordance with 7.2.2.4 shall be provided at the open sides of 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 the guards provided at the open side of the exit stair landings were not less than 42 inches high as per 7.2.2.4.5.2. Reference is made to the guards provided at the open side of the landings within exit stair A and B that were 30 inches high from the landings. The findings include: On (MONTH) 20, (YEAR), between 10:00 AM to 3:30 PM, during the annual recertification survey, it was observed that the facility had provided guard rails at the open side of the stair landings within exit stair A and B. The guards were measuring approximately 30 inches high from the floor of the stair landing. Examples Include: the top landings in stair A and stair B, the stair A landing at the 2nd floor level and the multiple guardrails at the first floor level within exit stair B. The guards installed at the open side of the landings must be at least 42 inches high from the adjacent floor (landings). On (MONTH) 20, (YEAR) at approximately 12:00 PM, the facility's Director of Maintenance stated that the existing guards at the open side of the stair landings will be extended to the required height. II. This Standard is not made as evidenced by: Section 7.2.2.4.2, states that required guards and handrails shall continue for the full length of each flight of stairs. At turns of new stairs, inside handrails shall be continuous between flights at landings. This standard is not met as evidenced by: Based on observation, it was determined that the facility did not ensure that handrails were provided for the full length of flight of exit stairs. Reference is made to the lack of handrails for the top section of flight of exit stairs leading to Carlton Avenue from the basement. The findings include: On (MONTH) 20, (YEAR), between 10:00 AM to 3:30 PM, it was observed that the flight of stairs leading to Carlton Avenue from the basement lacked handrails at the top section of the stairs. Handrails must be provided for the full length of each flight of the stairs. On (MONTH) 20, (YEAR) at approximately 1:30 PM , the facility's Director of Maintenance stated that the handrails will be installed for the full length of flight of stairs leading to Carlton Avenue from the basement, as per 7.2.2.4.2. 711.2 (a)(1) 2012 NFPA 101

Plan of Correction: ApprovedOctober 4, 2017

Element #1 - A welder has been contacted to extend or reinstall all handrails to correct height.
Element #2 - The entire facility could potentially have this type of violation
Element #3 - An In-service was provided by the Administrator to the Maintenance Department regarding the use of and rationale for preventative maintenance checklist. Checking for the correct height and completeness of guard rails, as well as the security of the guard rails, will be added to the environment audit checklist. For eight weeks the maintenance department will conduct preventative maintenance audit, one floor per day. After eight weeks, these audits will continue, minimally, one floor per week. All audits will be provided each Friday to the Administrator. Deficient items will be corrected as ascertained during these audits.
Element #4 - The Administrator is responsible for reviewing these audits and presenting the findings to the QAPI Committee. The Administrator will do random audits at least one floor per week for eight weeks, to validate compliance with plan of correction.

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

REGULATION: N/A

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 19, 2017
Corrected date: November 13, 2017

Citation Details

Physical Plant Violation - State Only 713-13 (j) East resident bed room shall have direct access to an outside exposure. The windowsills shall not be higher than three feet above the finished floor, and shall be above grade. This requirement is not met as evidenced by: Based on observation, it was determined that the facility did not ensure that resident room windowsills were not higher than 36 inches. Reference is made to a number of room windowsills that were approximately 4-1/2 ft. high from the floor (room #'s 207, 208, 210, 214). The findings include: On (MONTH) 20, (YEAR), at 10:00 AM to 3:30 PM, it was observed that the windowsills in a number of resident rooms were approximately 4-1/2 ft. high from the floor instead of the maximum of three feet. Examples were: room #'s 207, 208, 210, 214. On (MONTH) 20,2017 at approximately 2:45 PM, the facility's Director of Maintenance and facility's Administrator stated that the facility had no existing waiver for this provision of NYCRR 713-1. The facility's Administrator stated that facility will be requesting a waiver for this provision from the Department. NYCRR 713-2.5 (b)(8) Visual privacy shall be provided for each resident in multi-bed rooms with non-combustble cubicle curtains. This requirement is not met as evidenced by :Physical Plant Violation - State Only 713-13 (j) East resident bed room shall have direct access to an outside exposure. The windowsills shall not be higher than three feet above the finished floor, and shall be above grade. This requirement is not met as evidenced by: Based on observation, it was determined that the facility did not ensure that resident room windowsills were not higher than 36 inches. Reference is made to a number of room windowsills that were approximately 4-1/2 ft. high from the floor (room #'s 207, 208, 210, 214). On (MONTH) 11, (YEAR), the facility submitted a Construction Waiver/Equivalency Request (Waiver ID No. 172W031) to the Bureau of Architecture and Engineering Review (BAER) requesting a waiver of the requirement that window sills be no more than 3 feet high. The request was received by BAER on (MONTH) 14, (YEAR). As of (MONTH) 3, (YEAR), the waiver application is pending review.

Plan of Correction: ApprovedOctober 4, 2017

Element 1- We immediately contacted an engineer to assist in the waiver process. We interviewed the interviewable residents in the rooms cited to determine if there was a negative impact on quality of life. Rooms are well ventilated and light. Staff opens windows as needed, or be resident request. Air conditioners are present. Therefore, no negative impact ascertained due to the height of the windows.
Element 2- We measured all windows in all rooms to determine how many windows are affected by the requirement that window sills not be greater than 36 inches from the floor. We have counted 17 windows. We ensured that there is no risk to the health and safety of the residents. Rooms are well ventilated and light and air conditioned. Windows are opened and/or closed by staff members as needed.
Element 3- We will continue to ensure that staff responds to requests of residents, or anticipates there needs depending on weather conditions, to open and/or close windows.
Element 4- Room temperature is now included on the weekly maintenance audit round sheet. Administrator randomly checks two room audits per week for three months to ensure the accuracy of completion and to ensure the comfort of the residents in rooms affected by window height.