Orzac Center for Extended Care & Rehabilitation

Life Safety Code section 19.3.1.1. requires that any vertical openings, such as stairways, be enclosed or protected in accordance with section 8.2.5 and that construction of the enclosure shall have not have less than a 1-hour fire resistance rating. In addition, Section 7.1.3.2.1 prohibits penetrations into and openings through an exit enclosure assembly that do not serve the exit.
Based on observations and interviews during the recertification survey, the facility did not ensure that penetrations into exit stairways were limited to those that serve the exit. Reference is made to unsealed cable penetrations found in exit stair enclosures of exit stairs " K " , and " J " , on the 2nd , 1st and basement floors. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
The findings were:
(a). On 12/13/11 between 9:14 AM and 2:02 PM, unsealed cable penetrations were found in the exit stair enclosures of Exit Stairs " K " and " J " on the 2nd and 1st floors and in Exit stair " J " enclosure in the basement. In addition, unprotected steel beams were found to have been incorporated in the construction of the top-of-wall assemblies of the enclosure fire barriers in the 1st and 2nd floor exit stairs " J " . As per concurrent interviews with the facility's Director of Engineering, he would have the penetrations sealed as soon as possible and would see if it was feasible to enclose the steel beams in fire resistance rated construction.
NFPA 101-2000 Life Safety Code: 19.3.1.1, 8.2.5
10NYCRR, 415.29 (a) (2)

Life Safety Code section 19.3.7.3 requires smoke barriers to be constructed in accordance with section 8.3 and shall have a fire resistance rating of not less than \'bd-hour.
Based on observations and interviews, the facility did not ensure that smoke barrier walls were constructed to have at least a \'bd-hour fire resistance rating. Reference is made to unsealed and/or improperly sealed penetrations that were found in 6 out of 7 smoke barrier walls that were inspected as part of this survey.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
The findings include but are not limited to the following:
(a). On 12/13/11 at approximately 9:20 to 11:53 AM, unsealed cable penetrations (vicinity of cross-corridor doors near Room 211, and the pantry) were found in a 2nd floor smoke barrier wall. In addition, a portion of the top-of-wall assembly of the above-mentioned 2nd floor smoke barrier wall was found to be partially sealed with mineral wool insulation. As per concurrent interview with the facility's Director of Engineering, he will have the penetrations sealed with the appropriate firestopping materials.
Unprotected steel beams were found to have been incorporated in the construction of the top-of-wall assemblies of 2nd and 1st floor smoke barrier walls (vicinity of the dining rooms and room 111 respectively). Additionally, an unsealed steel bracket penetration was found in a 1st floor smoke barrier wall (above the cross-corridor doors near Room 111). As per concurrent interview with the facility's Director of Engineering, he would see if it was feasible to enclose the steel beams in fire resistance rated construction and will have the penetration sealed with the appropriate fire stopping materials.
Partially sealed steel u-channel and duct penetrations were found in a 1st floor smoke barrier wall (vicinity of the storage alcove near the Nurse Manager's Office and the Medication Room). As per concurrent interview with the facility's Director of Engineering, he will have the penetration sealed with the appropriate fire stopping materials.
On 12/14/11 at approximately 8:14 AM, an unprotected steel beam was found to have been incorporated in the construction of the top-of-wall assembly of a basement smoke barrier wall (vicinity of an office within the Adult Day Health Care program suite). As per concurrent interview with the facility's Director of Engineering, he would see if it was feasible to enclose the steel beam in fire resistance rated construction.
NFPA 101-2000 Life Safety Code: 19.3.7.3, 8.3
10NYCRR, 415.29 (a) (2)

Life Safety Code section 19.3.4.1 requires that existing health care occupancies be provided with a fire alarm system in accordance with section 9.6. Section 9.6.1.4 requires that the fire alarm system be installed, tested, and maintained in accordance with the requirements of NFPA 70, \i National Electrical Code and NFPA 72, \i National Fire Alarm Code. NFPA 72 section 7-3.1 requires that fire alarm system initiating devices be visually inspected at least twice a year.
Based on record review and interview, the facility did not ensure that fire alarm system initiating devices were visually inspected at least twice a year. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
The findings were:
On the morning of 12/14/11, review of fire alarm system revealed that the fire alarm system initiating devices were visually inspected only once in 2010.
Interview with facility's Director of Engineering revealed that the facility only had the fire alarm system initiating devices visually inspected once per year and that he was not aware that these devices must be inspected at least twice a year. He said that he will ensure that in the future the system is visually inspected at least twice a year.
NFPA 101-2000 Life Safety Code: 19.3.4, 9.6, NFPA 72-1999 National Fire Alarm Code: 7-3.1, Table 7-3.1
10NYCRR, 415.29 (a) (2)

Life Safety Code Section 19.1.1.4.1 requires that if the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a two hour fire resistance rating constructed of appropriate materials. Section 19.1.1.4.2 requires that communicating openings in dividing barriers required by 19.1.1.4.1 are only permitted in corridors and shall be protected by approved self-closing fire doors.
Based on observations and staff interviews during the recertification survey, the facility did not ensure that a code compliant 2-hour fire barrier separated the building housing the skilled nursing facility from an adjacent non-conforming building. Specific reference is made to unsealed penetrations and a hole in the 1st floor fire barrier that separated the skilled nursing facility from the adjacent three (3) story acute care hospital. This hospital building is of Type II (000) unprotected, noncombustible construction. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
The findings were:
On 12/13/11 at approximately 11:25 AM, a partially sealed duct penetration and an unsealed top-of-wall assembly were found in a 2-hour fire resistance rated building separation fire barrier (vicinity of cross-corridor doors near the 1st floor Nursing Administration Office). In addition, an approximately 2-inch by 2-inch hole was found in one side of a 2-hour fire resistance rated building separation fire barrier (vicinity of cross-corridor doors near the 1st floor Exit Stair " C " ). As per concurrent interviews with the Director of Support Services and Director of Engineering, they would have the penetrations and holes sealed as soon as possible.
NFPA 101-2000 Life Safety Code: 19.1.1.4.1
10NYCRR, 415.29 (a) (2)ne

Life Safety Code section 19.3.6.3 requires that doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1 \'be-inch thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. The requirement for doors to resist the passage of smoke applies to corridor doors in both sprinkler protected and non-sprinkler protected smoke compartments. In addition, corridor doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction (e.g., doors shall be provided with positive latching hardware).
Based on observations and interviews during the recertification survey, the facility did not ensure that all corridor doors were provided with approved positive latching hardware. Specific reference is made to the lack of positive latching hardware (e.g., automatic flush bolts). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
The findings were:
On 12/13/11 at 2:43 PM, the inactive leaf of the pair of doors to the basement Clean Linen Room was not provided with an automatic flush bolt or similar device to ensure positive latching of the pair of doors (i.e., these doors were provided with manually operated sliding bolt latching device). As per concurrent interview with the facility's Corporate Director of Safety, he would have an automatic flush bolt latching device installed on this door.
On 12/14/11 at approximately 8:40 AM, the inactive leaf of the pair of doors to the basement Storage Room (vicinity of the Home Health Office and Machine Room #21) was not provided with an automatic flush bolt or similar device to ensure positive latching of the pair of doors (i.e., these doors were provided with manually operated sliding bolt latching device). As per concurrent interview with the facility's Fire/Life safety Coordinator, he would have an automatic flush bolt latching device installed on this door.
NFPA 101-2000 Life Safety Code: 19.3.6.3
10NYCRR, 415.29 (a) (2)

Life Safety Code section 19.2.2.2.6 requires that any door in a hazardous room enclosure are permitted to be held open only be devices that are arranged to automatically close all such doors by zone or throughout the facility upon activation of:
(a) The required manual fire alarm and
(b) Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection systems and
(c) The automatic sprinkler system, if installed.
Based on observations and interviews, the facility did not ensure that only permitted devices were used to hold open doors to hazardous enclosures. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
The finding was:
On 12/13/11 at approximately 1:38 PM, a garbage can was found to be improperly used as a hold open device on a smoke barrier door to the Adult Day Health Care Center Activities Room in the basement. The facility's Fire/Life safety Coordinator took immediate corrective action by removing the garbage can. As per concurrent interview with the facility's Fire/Life safety Coordinator, he will have an approved electromagnetic hold-open device that is connected to fire alarm system installed on this door.
NFPA 101-2000 Life Safety Code: 19.2.2.2.6
10NYCRR, 415.29 (a) (2

Life Safety Code section 9.1.2 requires that electrical wiring and equipment be in accordance with NFPA 70, \i National Electrical Code.
Based on observations and interviews, the facility did not ensure that Information Technology Rooms were separated from other occupancies by 1-hour fire-resistant-rated walls, floors, and ceilings with protected openings. In addition, electrical wiring was not installed in a neat and workman like manner or maintained in good repair.
This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
The finding was:
On 12/13/11 at 10:58 AM to 2:25 PM, the following observations were made: door to a newly constructed Information Technology Room on the 1st floor (vicinity of the dining room) was found to lack a self-closing device, electrical junction boxes located above the suspended ceiling in the 2nd floor (vicinity of the pantry) and in the basement (vicinity of the interventional procedures room were found to lack cover plates on one side
As per concurrent interviews with the facility's Director of engineering, he would ensure that a self-closing fire door is installed and have the cover plates installed as soon as possible.
On 12/14/11 at approximately 8:55 AM, spliced wiring connections that were not enclosed within an approved electrical junction box were in a storage room located underneath the exterior exit ramp. As per concurrent interview with a facility maintenance worker he believed that this was old wiring and that it was no longer connected to an electrical power source. He said that he would have it removed as soon as possible.
NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Articles 645-2 and 110-12.
10NYCRR, 415.29 (a) (2)

Life Safety Code Section 19.3.2.1 requires that doors to hazardous area enclosures be self-closing or automatic-closing.
Based on observations and staff interview during the recertification survey, the facility did not ensure that all corridor door openings from hazardous areas were protected by self-closing, positive latching doors. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
The finding was:
On 12/14/11 at approximately 8:40 AM, one (1) of the two (2) doors to a basement Physical Therapy unit storage room was found to lack a self-closing device. As per concurrent interview with the facility's Director of Engineering, he would have a self-closing device installed on this door as soon as possible.
NFPA 101-2000Life Safety Code: 19.3.2.1
10NYCRR, 415.29 (a) (2)

Section 19.5.4 of the Life Safety Code requires that any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall comply with Section 9.5 and be provided with automatic extinguishing protection in accordance with Section 9.7.
Section 9.5.1 requires that rubbish chutes and laundry chutes shall be separately enclosed by walls or partitions in accordance with the provisions of Section 8.2. Inlet openings serving chutes shall be protected in accordance with Section 8.2. Doors of such chutes shall open only to a room that is designed and used exclusively for accessing the chute opening. The room shall be separated from other spaces in accordance with Section 8.4.
Section 9.5.2 requires that rubbish chutes, laundry chutes, and incinerators shall be installed and maintained in accordance with NFPA 82, Standard on Incinerators and Waste and Linen Handling Systems and Equipment, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.
NFPA 82 Section 3-2.2.9 requires that gravity chutes shall be constructed so that the base opening of the chute or shaft, or both, shall be protected by an approved automatic-closing or self-closing 1-hour fire door suitable for a Class B opening.
NFPA 82 Section 3-2.6.1 requires that waste and linen chutes shall terminate or discharge directly into a room having a minimum fire resistance rating not less than that specified for the chute (which would be 1-hour). Openings to such rooms shall be protected by approved automatic-closing or self-closing 1 -hour fire doors suitable for Class B openings.
Based on observations and staff interviews during the recertification survey, the facility did not ensure that the soiled linen chute discharge room was enclosed with at least 1-hour fire resistance rated construction and that fire doors on the linen chute were maintained in good repair.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
The findings were:

On 12/13/11 at approximately 1:22 PM, the fusible link device that would be used to close the fire door at the base of the chute (located within the basement soiled linen chute discharge room) in the event of a fire had been removed. Several unsealed cable and plumbing penetrations, two (2) plumbing penetrations that were improperly sealed with a non-fire resistance rated material(e.g., sealed with joint compound) and a joist penetration that was only sealed with mineral wool were found in the basement soiled linen chute discharge room. In addition, an unprotected steel beam was found to have been incorporated in the construction of the top-of-wall assembly in one of the enclosure fire barrier walls in this room.
As per concurrent interviews with the facility's Fire/Life Safety Coordinator and the Director of Engineering, the issue with the fusible link would be corrected immediately and the engineering director said he would have the penetrations sealed and would ensure that the room is enclosed in at least 1-hour fire resistance rated construction.
NFPA 101-2000 Life Safety Code: 19.5.4, 9.5, NFPA 82-1999 Standard on Incinerators and Waste and Linen Handling Systems and Equipment: 3-2
10NYCRR, 415.29 (a) (2)

Life Safety Code Section 19.3.2.4 requires that medical gas storage and administration areas are in accordance with NFPA 99, Standard for Healthcare Facilities. NFPA 99 Section 4-3.1.1.2 (b) (3) requires that the walls, floors, and ceilings of locations for supply systems of more than 3000 ft3 (85 m3) total capacity (connected and in storage) separating the supply system location from other occupancies in a building shall have a fire resistance rating of at least 1 hour. This shall also apply to a common wall or walls of a supply system location attached to a building having other occupancy.
Based on observations and staff interviews during the recertification survey, the facility did not ensure that oxygen storage rooms that contained over 3,000 cubic feet of compressed oxygen were enclosed by fire barriers that had a fire resistance rating of at least 1 hour. Reference is made to penetrations found in one of the enclosure walls in the storage room.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
The finding was:
On 12/13/11 at approximately 1:08 PM, an unsealed cable penetration was found in one of the enclosure walls of the large oxygen storage room in the basement. As per concurrent interview with the facility's Director of engineering, he will have this penetrations sealed immediately.
NFPA 101-2000 Life Safety Code: 19.3.2.4, NFPA 99-1999 Standard for Healthcare Facilities: 4-3.1.1.2 (b) (3)
10NYCRR, 415.29 (a) (2)

1. Based on observations and staff interviews during the recertification survey, the facility did not ensure that exterior ramps that are used as a component in the means of egress were maintained in good repair. This resulted in no actual harm with potential for more than minimum harm that is not immediate jeopardy.
The finding was:
On 12/14/11 at approximately 9:05 AM, an approximately 5-foot long section of handrail was missing from the lower portion of an exterior exit ramp that serves as one of the means of egress from the building. As per concurrent interview with the facility's Director of Support Services, the handrail had been struck by a truck making a delivery only a few days earlier and that the facility had already ordered a replacement handrail.
NFPA 101-2000Life Safety Code: 19.2.2.6, 7.2.5.3, 7.2.5.4
10NYCRR, 415.29 (a) (2)
2. Based on observations and staff interview during the recertification survey, the facility did not ensure that elevator machine rooms were enclosed in at least 1-hour fire resistance rated barriers. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
The findings were:
On 12/13/11 at approximately 1:45 PM, a duct opening located in 1-hour fire resistance rated suspended ceiling assembly in basement Machine Room #s 20 and 17 (elevator equipment rooms) were found to lack fire dampers. As per concurrent interview with the facility's Director of Engineering, he would have fire dampers installed.
NFPA 101-2000 Life Safety Code: 19.5.3, 9.4.6, ASME/ANSI A17.1 Safety Code for Elevators and Escalators, 10NYCRR, 415.29 (a) (2)
3. Based on observations and staff interview during the recertification survey, the facility did not ensure that fire safety related parking regulations were followed. Reference is made to motorized vehicles that were illegally parked in a lane identified as " FIRE LANE-NO PARKING ANYTIME " on the east side of the building housing the skilled nursing facility.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
The findings were:
(a). Observations made on the morning and afternoon of 12/13/11 and the morning and afternoon on 12/14/11 revealed that there were usually four or more cars parked in a lane identified as " FIRE LANE-NO PARKING ANYTIME " on the east side of the building housing the skilled nursing facility. This fire lane (fire apparatus access road) was marked both by signage and painted identification on the pavement.
As per interview with the facility's Director of Support Services on 12/13/11 at approximately 11:19 AM, the cars are being parked by the valets in the fire lanes. He said that this issue had already been raised by the Nassau County Fire Marshal's Office and that the facility is in the process of constructing a new parking lot and that once this parking lot is completed it would eliminate the need for the valets to leave cars parked in any marked fire lanes.

NFPA 101-2000 Life Safety Code: 4.2.3, 4.6.1.2,
10NYCRR, 415.29 (a) (2)

NFPA 101, Life Safety Code section 19.3.1.1 requires any vertical openings be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall not have less than a 1-hour fire resistance rating.
Section 8.2.5.6 requires that in buildings that contain an atrium that the building be protected throughout by an approved, supervised automatic sprinkler system installed in accordance with Section 9.7.
Based on observations and staff interview during the recertification survey, the facility did not ensure that the building was provided with complete sprinkler protection and that all vertical openings in the building were enclosed or protected in accordance with the Life Safety Code. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
The findings were:
On the morning of 12/13/11, it was noted that the building housing the skilled nursing facility had an atrium that connected the first and second floors of the building and that the front entrance vestibule within the atrium space was not provided with automatic sprinkler protection. As per interview with the facility's Director of Engineering on 12/13/11 at 11:12 AM, he would have sprinkler protection installed in the entrance vestibule.
On 12/14/11 at approximately 8:19 AM, a vertical plumbing penetration in a basement corridor (vicinity of the entrance to the Adult Day Health Care Center Activities Room and Machine Room #20) was found to have been improperly sealed with a non-fire resistance rated material (e.g., polyurethane expansion foam). As per concurrent interview with the facility's Fire/Life safety Coordinator, he would have the non-fire resistant rated materials removed and would re-seal the plumbing penetration with approved materials.
NFPA 101-2000 Life Safety Code: 19.3.1.1, 8.2.5 , NFPA 13
10NYCRR, 415.29 (a) (2)ne

Life Safety Code section 19.5.2.1 requires that all heating, ventilating, and air conditioning systems comply with the provisions in section 9.2. Life Safety Code section 9.2.1 requires that all heating, ventilating, and air conditioning ductwork and related equipment be installed and maintained in accordance with NFPA 90A, \i Standard for the Installation Conditioning and Ventilating Systems. NFPA 90A does not permit the use egress corridors in health care occupancies as a portion of a supply, return, or exhaust air system serving an adjoining area. Air transfer openings are not be permitted in walls or in doors separating egress corridors from adjoining areas.

Based on observations and interviews, the facility did not ensure that the interstitial spaces above suspended ceilings in egress corridors were not used as a portion of a supply, return, or exhaust air system. This has the potential for more than minimal harm to residents but no actual harm has occurred.
The findings were:

On 12/14/11 between 1:10 and 2:00 PM, open (i.e., non-ducted) air transfer openings (approximately 12-inches by 4-inches) were found in corridor walls above the suspended ceiling in the vicinity of the basement Oxygen Storage Room and machine room # 17. In addition, an approximately 12-inch by 12-inch open (i.e., an non-ducted) air transfer opening (approximately 12-inches by 4-inches) was found above the suspended ceiling of a basement exit access corridor (vicinity of the Adult Day Healthcare unit and the Nurse Educator's Office).As per concurrent interview with a facility maintenance worker, the space above the suspended ceiling in the exit access corridor was being used as a return air plenum. He said that this is a condition that goes back to the original construction of this building and that the facility is in the process of correcting this issue and that this condition now only exists in a fairly small portion of the building (e.g., the areas near the beauty shop, the Adult Day Healthcare unit). And in additional interviews with the facility's Fire/Life safety Coordinator and their Corporate Director of Safety, the facility will take corrective action as soon as possible.
NFPA 101-2000 Life Safety Code: 19.5.2.1, 9-2, NFPA 90A-1999 2-3.11.1
10NYCRR, 415.29 (a) (2)