Menorah Home & Hospital for Aged & Infirm

Based on observation , it was determined that the facility did not ensure that residents' use areas in the partially sprinklered old building are equipped with at least single station battery-operated smoke detectors. Reference is made to the physical therapy area and the occupational therapy areas, in the old building that were not equipped with at least, battery operated smoke detectors.

This resulted in no actual harm with potential for greater than minimal harm that is not immediate je o pardy.

The findings include:
On July 19, 2011 and July 20, 2011 at 9:30 AM to 2:30 PM, it was observed that the facility old building is partially sprinklered. The physical therapy area and the occupational therapy areas, in the old building were not provided with at least battery-operated smoke detectors. On July 20, 2011, at approximately 12:00 PM, the facility's director of facilities management stated that single station battery-operated smoke detectors will be installed in all resident areas in the old building.

711.2 (a)(1)

This standard is not met as evidenced by:
Based on observation, it was determined that the facility did not ensure that egress doors, which are installed in pairs from the physical therapy room and occupational therapy room on the 4th floor, are provided with positive latching devices. Reference is made to the lack of approved automatic flush bolts for the stationary door leaf of the two leaf doors.

This resulted in no actual harm with potential for greater than minimal harm that is not immediate je o pardy.

The findings include:
On July 19, 2011 and July 20, 2011 , at 9:30 AM to 2:30 PM, it was observed that the facility building "A", where the physical and occupational therapy area are located, is a partially sprinklered building. The corridor opening from the physical therapy room and the occupational therapy room are protected with magnetically held open doors installed in pairs. The stationary door leaves of the two leaf doors were equipped with the thumb operating concealed manual latching devices and not the approved automatic flush bolts, so as to achieve the positive latching mechanism of these doors upon closing. On July 20, 2011, at approximately 10:30 AM, the facility's director of facilities management stated that the stationary leaf doors to the physical therapy room and the occupational therapy room will be equipped with the approved automatic flush bolt devices in order to achieve the positive latching mechanism.

711.2 (a)(1)

Based on observation, it was determined that the facility did not ensure that the sprinkler control valve located within exit stairway "A", on the 4th floor level and within stair "I" on the 3rd floor level in the old building were electrically supervised.

This resulted in no actual harm with potential for greater than minimal harm that is not immediate je o pardy.

The findings include:
On July 19, 2011 and July 20, 2011 at 9:30 AM to 2:30 PM, it was observed that the facility old building is a partially sprinklered building. Resident service areas ( physical therapy, occupational therapy and beauty parlor) are located in the old building. The sectional sprinkler control valves located within exit stairway "A" on 4th floor and within exit stair "G"on 3rd floor level, in the old building were lacking electrical supervision, so that an alarm will sound at a previously designated location within the building when the valves are closed. On July 20, 2011, at approximately 12:30 PM, the facility's director of facilities management stated that all sprinkler control valves will be electrically supervised.

711.2 (a)(1)

This standard is not met as evidenced by:
Based on observation, it was determined that the facility did not ensure that the enclosing walls to the elevator machine room #E116 was not provided with transfer grilles, regardless of wether they are protected by fusible link - operated dampers,as per 19.3.6.4.

This resulted in no actual harm with potential for greater than minimal harm that is not immediate je o pardy.

The findings include:
On July 19, 2011 and July 20, 2011 , at 9:30 AM to 2:30 PM, it was observed that the corridor wall to the elevator machine room #E116, in the old building, was provided with transfer grilles (ventilation louvers). The presence of these transfer grills does not ensure the fire/smoke separation of the use area from the corridor. On July 20, 2011,at approximately 10:45 AM, the facility's director of facilities management stated that the louvers to the elevator machine room will be sealed.

711.2 (a)(1)

This standard is not met as evidenced by:
Based on observation, it was determined that the facility did not ensure that the doors to the hazardous areas are only held open with approved automatic releasing devices activated via the fire alarm systems of the facility, as per 7.2.1.8.2 and 19.2.2.2.6. Reference is made to the door to the trash chute room #E153, at the first floor of old building that was held open with rubber like stopper.

This resulted in no actual harm with potential for greater than minimal harm that is not immediate je o pardy.

The findings include:
On July 19, 2011 and July 20, 2011 at 9:30 AM to 2:30 PM, it was observed that the door to the trash chute room #153 in the old building was held open with a rubber like stopper wedged under the door. This door held open device would not allow the door to be released automatically upon the activation of the facility's fire alarm system, sprinkler system and the smoke detection system as required under 19.1.1.4.3, 19.2.2.2..6 and 7.2.1.8.2. On July 20,, 2011, at approximately 11:15 AM, the facility's director of facilities management stated that the unapproved door hold open device will be removed from the door to the hazardous areas.

711.2 (a)(1)

NYCRR 713- 3.25 (g)(1):

(g) Nurse's calling system s shall comply with the following :
(1) A call button shall be provided at each resident bedside, which calls to the nurse's station. . Two call buttons serving adjacent beds may be served by one calling station. Calls shall register with the floor staff and shall activate a visible signal in the corridor at the patient 's d oor, in the clean workroom, in the soiled workroom, and in the nourishment station of the nursing unit. In multi-corridor nursing units, additional visible signals shall be installed at the corridor intersections. In rooms containing two or more calling stations, indicating lights shall be provided at each station. Nurses' calling systems that provide two-way voice communication shall be equipped with an indicating light at each calling station with lights, and remain lighted as long as the voice circuit is operating.

This requirement is not met as evidenced by:
Based on observation, it was determined that the facility did not ensure that nurses' calling system is designed to activate a visible signal in the clean workroom ( medication rooms) of the nursing units when calls are placed by the residents from their bedrooms or toilet facilities.

The findings include:
On July 19, 2011 and July 20, 2011 at 9:30 AM to 2:30 PM, it was observed that the nursing units on 1-4 floors in the new building are provided with clean workrooms which are identified as medication rooms. The medication rooms contain work counter, handwashing sink, medications, clean supplies and storage cabinets. The nursing staff occupy the medication rooms for extended period of time while preparing medications or performing clean tasks. The medication rooms lack the registering of nurses' call visual signals when calls are placed by the residents from their bedrooms or toilet rooms. Such clean workrooms are required to be equipped with the call registering stations so as to activate a visual signal when calls are placed by the residents. On July 20, 2011, at approximately 1:30 PM, the facility's director of facilities management stated that the medication rooms were deemed acceptable during the reopening of the building. The director further stated that if required, call registering stations (duty stations) will be installed in the medication rooms of the nursing units.

This standard is not met as evidenced by:
Based on observation, it was determined that the facility did not ensure that vision panels in the corridor wall to the beauty salon on the 4th floor in the old building, are the fixed window assemblies in approved frames. Reference is made to the clear glass vision panels, of unknown fire resistance rating in the corridor wall to the beauty parlor.

This resulted in no actual harm with potential for greater than minimal harm that is not immediate je o pardy.

The findings include:
On July 19, 2011 and July 20, 2011 , at 9:30 AM to 2:30 PM, it was observed that the smoke compartment containing the beauty parlor, on the 4th floor, in old building, is partially sprinklered. The corridor wall to the beauty salon has four clear glass vision panels measuring approximately 18 inches x 18 inches each. Facility did not provide any documentation to show the fire resistance rating of these vision panels. Vision panels installed in corridor walls to the resident use areas continued in a partially sprinklered smoke compartment are to be approved fixed window assemblies. On July 20, 2011, at approximately 11:00 AM, the facility's director of facilities management stated that either the vision panels will be replaced with approved window assemblies or the smoke compartment containing the beauty salon will be protected with the complete sprinkler system.

711.2 (a)(1)

The following waiver (s) is (are) on file with this office. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the condition under which the waivers have been granted have not changed. Please indicate if the facility wishes the waiver(s) to be continued.

Please indicate if the facility wishes the waiver (s) to be continued or provide a plan of correction.

K 130 S/S=B
NFPA 101 - 13-3.5 - 19.3.5.1 where required by 19.1.6 health care facilities shall be protected throughout by an approved supervised automatic sprinkler system in accordance with section 9.7.
Buildings containing health care facilities shall be protected throughout by an approved,supervised automatic sprinkler system installed in accordance with section 7-7.

Staircases in the new building are not sprinklered.

The following waiver (s) is (are) on file with this office. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the condition under which the waivers have been granted have not changed. Please indicate if the facility wishes the waive(s) to be continued.

Include your request for renewal of this waiver or plan of correction in the space provided on this form.

Please indicate if the facility wishes the waiver (s) to be continued or provide a plan of correction.

42 CFR 483.70(a):

The vertical ventilation ducts in the toilets of some patient/resident rooms(i.e., rooms 235 and 237 as well as rooms 221 and 223) cross the smoke barriers according to the architectural plans. These ducts do not contain smoke dampers actuated by smoke and constructed, located and installed in accordance with the requirements of NFPA 90A.
LSC 13-3.7.1, NYCRR 711.2(a)(1)