New East Side Nursing Home
April 28, 2017 Certification Survey

Standard Health Citations

FF10 483.60(i)(4):DISPOSE GARBAGE & REFUSE PROPERLY

REGULATION: (i)(4)- Dispose of garbage and refuse properly.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 28, 2017
Corrected date: May 15, 2017

Citation Details

Based on observation, interview and record review the facility did not ensure that garbage and refuse were disposed of properly. Specifically, three (3) commercial garbage bins were observed not to be properly covered. In addition, the area adjacent to and surrounding the bins was full of debris. This was observed during the Kitchen/Food observation task. The findings are: On 4/25/17, at approximately 9:45AM the State Surveyor(SA) conducted an observation of the facility's garbage storage area with the facility Food Service Director. The following were observed: behind the metal gate were three metal commercial garbage bins. The three bins contained closed black garbage bags which were visible at the top of the bins. Each bin had intact heavy gauge plastic lids. The lids were attached to the garbage bins but were not covering the bins. The following litter was observed on the concrete floor adjacent to the bins: one soda can, one latex glove, a piece of a wet corrugated box, and other various smaller pieces of refuse. On 4/27/17 at 9:50 AM the outside area that holds three commercial garbage bins was observed. The three bins have moveable, black plastic lids but they were not covering the bins which were holding multiple black plastic garbage bags. The concrete floor was littered with one soda can, one clear plastic drink bottle, used latex gloves, one piece of saturated corrugated paper box and other various smaller pieces of refuse. On 4/28/17 at 9:25 AM the same area was observed. The three garbage bins were empty but the bins remain uncovered. The concrete floor was littered with afore-mentioned refuse. On 4/28/17 at approximately 11:41 AM this SA met with the Director of Housekeeping and together went outside to the garbage holding area. He slid the gate to the left and viewed the uncovered garbage containers and the concrete floor. He pulled out the middle rolling bin and on the floor behind the bins were 3 black garbage bags and saturated corrugated paper boxes which were tied up and approximately 12 high. On 4/28/17 at 11:48 AM the Director of Housekeeping was interviewed and stated, The garbage bins are supposed to be covered with the lids. The staff member who is assigned to maintain the area has been out for approximately one month due to surgery. While the other person was out I should have been monitoring the area. I will clean up the litter and garbage on the floor. He then proceeded to cover all the bins and close the gate. The facility's policy titled, Waste Disposal dated 4/28/17 documented, It is the policy of The New East Side Nursing to dispose of its kitchen and household waste in a proper and sanitary manner. 415.14 (h)

Plan of Correction: ApprovedMay 10, 2017

F372
1. Immediate Corrections : The Director of Housekeeping promptly assigned an employee to remove the debris from the concrete floor adjacent to the garbage bin and ensured that the bins were properly covered.
2. All residents potentially affected.
3. Daily, the Housekeeping Supervisor will assign an employee with the responsibility of making certain the garbage area is properly maintained. The employee will document the inspection on an audit sheet.
The Administrator will in-service the housekeeping and dietary staff on the facility's policy on the proper storage and disposal of garbage.
4. The Director of Housekeeping will devise an audit tool to routinely monitor the proper storage and disposal of garbage. The Housekeeping department and/or the Dietary department will conduct this audit daily times three months. Negative findings will be corrected promptly. Reports of these rounds will be reported to the quarterly QA committee for evaluation and follow up as indicated.
5. The Administrator is responsible for ensuring the corrective action is implemented and that the condition does not arise again.

Standard Life Safety Code Citations

K307 NFPA 101:CORRIDOR - DOORS

REGULATION: Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 28, 2017
Corrected date: May 31, 2017

Citation Details

Based on observation, it was determined that the facility did not ensure that the corridor door to the use areas was provided with suitable latching devices. Reference is made to the the corridor door to the accounting office on the first floor that was not provided with a positive latching device. The findings include: On (MONTH) 25,2017 at 9:30 AM to 3:30 PM, it was observed that the corridor door to the accounting office on the first floor, lacked an appropriate latching device. Doors protecting corridor openings to the use areas must be provided with positive latching hardware. On (MONTH) 25, (YEAR) at approximately 12:00 PM,the facility's Director of Maintenance stated that the corridor door to the accounting office will be provided with positive latching hardware. 711.2 (a)(1) 2012 NFPA 101

Plan of Correction: ApprovedMay 17, 2017

1. No residents specifically identified to have been affected by the deficient practice.
2. All residents have the potential to be affected by the deficient practice.
3.To ensure the deficient practice will not recur the corridor door to the Accounting office will be provided with a positive latching device.
To monitor the deficient practice and ensure that it does not recur the Director of maintenance will, on a monthly basis, inspect the corridor door to the accounting office.
This audit will occur for a period of one year and will then be reviewed for necessity
5.The Administrator will be responsible for correcting K363

K307 NFPA 101:DOORS WITH SELF-CLOSING DEVICES

REGULATION: Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 28, 2017
Corrected date: May 27, 2017

Citation Details

Based on observation, it was determined that the facility did not ensure that the doors to hazardous areas were kept closed or held open with approved hold open devices that would release upon activation of the facility fire alarm systems, as per 7.2.1.8.2. Reference is made to the door to the file storage room on the 4th floor that was kept open with the conventional magnetic device that would not release upon activation of the facility fire alarm system. The findings are: On (MONTH) 25,2017 between 9:30 AM to 3:30 PM, it was observed that the door to the storage room on the 4th floor, storing hazardous quantities of cartons of record files, was held open with the conventional magnetic device. Such device would not release upon activation of the facility fire alarm system, as per 7.2.1.8.2. On (MONTH) 25, (YEAR) at approximately 1:00 PM, the facility's Director of Maintenance stated that the conventional magnetic door open device was being removed from the door to the file storage room and the door will be kept in the closed position. 711.2(a)(1) 2012 NFPA 101

Plan of Correction: ApprovedMay 16, 2017

1. No residents specifically identified to have been affected by the deficient practice.
2. All residents have the potential to be affected by the deficient practice.
3. To ensure the deficient practice will not recur the following measures will be put into effect:
a. Doors to hazardous areas will be inspected on a monthly basis by Administrator/designee to ensure no unapproved hold open devices are utilized in the facility.
b. The 4th floor Medical Record room hold open device was removed.
4. To ensure the deficient practice does not recur a monthly QA audit will be will be conducted by the Administrator/designee of the hazardous storage ares to ensure that only approved hold open devices are utilized and these reports will be brought to the QA meeting on a quarterly basis for review.
5. The Administrator is responsible for the correction of K223.

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 28, 2017
Corrected date: June 16, 2017

Citation Details

Based on observation, it was determined that the facility did not ensure that the sprinklered hazardous areas were separated by at least smoke resistive partitions and the doors protecting the openings to the hazardous areas were self-closing and positive latching. Reference is made to the presence of a large hole penetrating the enclosure walls to the dietary storage room; the door to the kitchen storage room that was not latching; and the door to the mattress storage room in the basement that was not latching in the door frame. The findings include: On (MONTH) 25,2017 at 9:30 AM to 3:00 PM,it was observed that the facility hazardous areas were provided with automatic fire extinguishing system. The enclosure wall to the kitchen storage room was penetrated by an approximately 12 inches x 4 inches hole, and the door to the kitchen storage room and the door to the mattress storage room in the basement were not latching in their door frames. The doors were either hitting the door frame or were not positive latching. On (MONTH) 25,2017 at approximately 11:45 AM,the facility's Director of Maintenance stated that the penetration to the kitchen storage room was being sealed and the doors to all storage rooms will be made positive latching. 711.2 (a)(1) 2012 NFPA 101

Plan of Correction: ApprovedMay 16, 2017

1. No residents specifically identified to have been affected by the deficient practice.
2. All residents have the potential to be affected by the deficient practice.
3. The kitchen storage room penetration to be sealed, doors to the mattress storage room and kitchen storage area to be adjusted so that the doors latch positively.
4. To monitor the corrective action for this deficient practice, the Director of Maintenance will inspect the door to the mattress storage room and the kitchen storage room on a monthly basis and report his findings on a QA audit form and these reports will be brought to the QA meeting on a quarterly basis.
5. The Administrator is responsible for the correction of K321

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: April 28, 2017
Corrected date: June 26, 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 approved automatic sprinkler system in accordance with section 9.7 and NFPA 13. Reference is made to the lack of sprinkler coverage in a number of areas in the building. Examples include: the overhang at the building entrance containing two window air conditioning units; the large vestibule in the kitchen; a section of the hood system in the kitchen;a section of the hood system containing dairy dishwasher; the deep ceiling pockets in the boiler room; the recessed area off the machine room in the basement; the storage alcove off the maintenance suite in the basement; the used area under the duct enclosure within maintenance suite in the basement; the top of the dumbwater shaft in the kitchen; the lack of identification of the sprinkler valves; storage closet off the library; the electrical closet on the 4th floor; vestibule to room [ROOM NUMBER]; obstructed sprinklers by solid shower curtains or walls in a number of shower rooms/toilet rooms off resident room and alcove area leading to East Stair on the 2nd floor. The findings include: On (MONTH) 25, (YEAR) at 9:30 AM to 3:30 PM,during the recertification survey of the facility, 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 areas: (1) The exterior non-combustible roof/overhang, measuring approximately 20 ft x 8 ft, containing two window air conditioning units, lacked sprinklers. (2) Lack of an automatic sprinkler at the top of the dumbwater shaft off the kitchen area. (3) The large vestibule (measuring approximately 8 feet deep) area, at the boiler room side entrance to the kitchen area, lacked sprinklers. (4) The exhaust hood system containing the dairy dishwasher within the kitchen. (5) The section of hood system containing the steam table in the kitchen lacked sprinklers. (6) An approximately 9 feet long vestibule area in the boiler room containing ceiling pockets, lacked sprinklers. (7) An approximately 4 feet deep recessed area off the machine room in the basement, lacked sprinkler coverage. (8) Approximately 6 feet deep storage alcove adjacent to the oxygen storage room off the maintenance suite, in the basement, lacked sprinklers. (9) The used area under the approximately 11 ft x 11 ft duct enclosure in maintenance suite in the basement lacked sprinklers. (10) At least two sprinkler control valves in the sprinkler control room and at least one sprinkler test valve located at the 2nd floor West Stair landing, lacked identification signs. 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. (11) The built-in type storage closet off the library area on the first floor lacked sprinklers. (12) The electrical closet,on the 4th floor, lacked sprinklers. The door to the closet was not labeled fire rated door. (13) An approximately 5 feet deep vestibule to room [ROOM NUMBER] containing resident storage closets lacked sprinklers. (14) The existing sprinklers were obstructed by solid type curtains or the partitioning walls within the shower room/toilet areas off a number of resident rooms (room #'s 302, 305, 306, 204, 201), so as not to provide coverage for the entire protected area. (15) In room [ROOM NUMBER] and # 209, the recessed area containing a handwashing sink had no sprinkler coverage. The existing sprinklers were obstructed by the turn of wall so as not to provide coverage for the recessed area. (16) The alcove area containing East Stair exit door lacked sprinkler coverage. On (MONTH) 25,2017 at approximately 2:30 PM,the facility's Director of Maintenance stated that the sprinkler company will be contacted to evaluate and provide automatic sprinklers in all areas of the building, as per NFPA 13. 711. 2(a)(1) 2012 NFPA 101 2010 NFPA 13

Plan of Correction: ApprovedMay 24, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1.For those residents found to have been affected in rooms 304,305,306, 204, 201,209 and 309 by the deficient practice the following will be completed:
a. For rooms 302,305,306,204 and 201 which have existing sprinkler coverage but have obstructions, partition walls will be cut down in toilet area so sprinkler coverage will protect the entire area.
b.For room [ROOM NUMBER] sprinkler coverage will be provided in vestibule area of resident room.
c. For room #'s 209 and 309 sprinkler coverage will be provided in recessed area containing a hand washing sink.
d. For all other areas listed in SOD, no other residents specifically identified.
2. All residents have potential to be affected by the deficient practice.
3. The following measures will be taken to ensure deficient practice does not recur:
a.Sprinkler vendor will be onsite to conduct and walk thru entire facility. All areas listed on SOD were observed and proper sprinkler coverage will be added.In addition to areas listed i the SOD sprinkler vendor made suggestions for areas not listed. Sprinkler coverage will be provided in these areas as well.
For areas listed in the SOD, specifically, the following measures will be taken
i.Roof Overhang - 2 air conditioners will be removed.
ii.Dumbwaiter shaft - Sprinkler coverage will provided at top.
iii. Large vestibule at boiler room side entrance to kitchen area will have sprinkler coverage provided.
iv. Exhaust hood - containing dairy dishwasher will have sprinkler coverage provided.
v. Steam table - section under kitchen hood will have sprinkler coverage provided.
vi.Vestibule area in boiler room containing ceiling pockets will have sprinkler coverage provided.
vii. Recessed area of machine room in basement will have sprinkler coverage provided.
viii.Storage alcove adjacent to oxygen room in maintenance suite will have sprinkler coverage provided.
ix. Used area under duct enclosure will have sprinkler coverage provided.
x. A sprinkler control valves throughout the facility will have appropriate signage.
xi. Built in storage closet in library will have appropriate sprinkler coverage provided.
xii. Electrical closet on 4th floor will have a new fire rated door installed.
xiii. Alcove area containing east stair exit will have sprinkler coverage provided.
4. In an effort to ensure the deficient practice does not recur and to monitor the sprinkler system and the coverage it provides, sprinkler vendor will visit facility on a quarterly basis to inspect system and will provide reports to Administrator/designee, and those reports will be reviewed with the Director of maintenance and brought to the QA team on a quarterly basis.
5. the Administrator is responsible for correcting K351

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: April 28, 2017
Corrected date: June 27, 2017

Citation Details

2012 NFPA 101, Section 7.2.2.4.1,states that means of egress that are more than 30 inches (26 cm) above the floor or grade below shall be provided with guards to prevent falls over the open side. 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 not less than 42 inches high from the adjacent floor surface. Reference is made to the guards provided at the open side of the top landings in the East and West exit stairs that were 36 inches high,instead of the minimum of 42 inches high from the adjacent floor surface (landings). The findings include: On (MONTH) 25,2017 at 9:30 AM to 3:30 PM, it was observed that the facility had provided guard rails at the open side of the top landings within the East and West exit stairs. The guards measured approximately 36 inches high from the adjacent floor surface (landings) in the East and West exit stairs. The guards installed at the open side of the landings can not be less than 42 inches high from the adjacent floor surface (landing). On (MONTH) 25,2017 at approximately 11:00 AM,the facility's Director of Maintenance stated that the guard rails will be extended to the required height. 711.2 (a)(1) 2012 NFPA 101

Plan of Correction: ApprovedMay 16, 2017

1. No specific residents have been identified to have been affected by the deficient practice.
2. All residents have the potential to be affected by the deficient practice.
3. To ensure the deficient practice will not recur the following systemic change will take place.
Exit stair landings on the east and west staircases, specifically at the top of the staircase guards will be extended to the required 42 instead of the 36 that were installed when the facility was originally built.
4. To monitor the deficient practice the Administrator/designee will visually inspect the east and west staircase landing at the top of the staircases where extensions will be installed.
The Administrator/designee will bring his report to the QA team on a quarterly basis.
5.The administrator is responsible for the correction of K225

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: April 28, 2017
Corrected date: June 27, 2017

Citation Details

Physical Plant Violation - State Only NYCRR 713-1.9 (f) (f) Kitchen areas shall have a mechanical ventilating system to maintain an equal supply and exhaust and a minimum of ten air changes per hour. Dishwashing areas shall have an exhaust system with a minimum of ten air changes per hour. If all outside air is used, a filter with at least thirty five percent efficiently shall be installed in the system. Supply air for the dishwashing area may be taken from the kitchen. All exhaust air shall be discharged directly to the outdoors. This requirement is not met as evidenced by: Based on observation and staff interview, it was determined that the facility did not ensure that the kitchen areas were mechanically ventilated and balanced to provide equal pressure relationship with adjacent areas,with a minimum of ten air changes per hour. Reference is made to the lack of mechanical air supply to the kitchen areas and lack of documentation to show that ventilation system was balanced for the required pressure relationship with adjacent areas. The findings include : On (MONTH) 25, (YEAR) at 9:30 AM to 3:30 PM, it was observed that the facility kitchen areas lack mechanical air supply system. An interview with the facility's Director of Maintenance revealed that the outdoor air supply system was probably at one time either a mechanical or gravity system. The system grilles were, however, non-functional for an unspecified time. In the absence of an air supply system, the mechanical exhaust via the hood system would create a negative pressure relationship with the adjacent areas. The facility must provide and balance the ventilation system in the kitchen to provide an equal supply and exhaust system with a minimum of ten air changes per hour supplied to the kitchen. On (MONTH) 25, (YEAR) at approximately 10:30 AM, the facility's Director of Maintenance stated that HVAC company will be contacted to evaluate and provide and balanced the ventilation system in the kitchen,as per 713-1.9.

Plan of Correction: ApprovedJune 13, 2017

1. No residents specifically identified found to have been affected in SOD
2.Residents do not frequent facility kitchen therefore no residents have the potential to be affected.
3. The following systemic change will occur to ensure deficient practice will not recur.
a. HVAC vendor immediately notified after exit conference with the sanitarian. HVAC vendor arrived to the facility to assess need as directed by sanitarian. HVAC vendor requested official document when received by facility so applicable code can be referenced and followed.
b. Facility Administrator forwarded SOD to HVAC vendor on 5/12/17. Vendor received and forwarded contract to engage services, document was signed and sent to vendor. Currently, facility is awaiting engineer to arrive and survey area and any applicable drawings and plans will be provided.
c. Facility will request a time limited waiver as task may exceed 60 day completion after survey exit date.
4. HVAC vendor will monitor newly installed system as per code requirements.
5. The Administrator is responsible for the correction of k560