Nursing Investigation Results -

Pennsylvania Department of Health
PROVIDENCE REHAB AND HEALTHCARE CENTER AT MERCY FITZGERALD
Building Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
PROVIDENCE REHAB AND HEALTHCARE CENTER AT MERCY FITZGERALD
Inspection Results For:

There are  30 surveys for this facility. Please select a date to view the survey results.

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PROVIDENCE REHAB AND HEALTHCARE CENTER AT MERCY FITZGERALD - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on January 30, 2019 at Providence Rehabilitation and Healthcare Center at Mercy Fitzgerald, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.


 Plan of Correction:


Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID# 074902
Component 01

Based on a Medicare/Medicaid Recertification Survey completed on January 30, 2019, it was determined that Providence Rehabilitation and Healthcare Center at Mercy Fitzgerald was not in compliance with the following requirements of the Life Safety Code for an existing long-term health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a two-story, Type II (111), protected non-combustible structure, with an attic, which is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0100

Based on observation and interview, it was determined the facility failed to secure plan approval by the Department of Health prior to initiating alterations and renovations, affecting the entire facility.

Findings include:
1. Observation and interview on January 30, 2019, at 1:00 pm, revealed the facility failed to secure plan approval by the Department of Health prior to initiating renovations that included replacing the rated ceiling assembly, flooring, wall coverings, handrails and lighting within the facility.
Interview at the exit conference with the Administrator, Regional Director of Plant Operations and the Maintenance Supervisor on January 30, 2019, at 2:50 pm, confirmed the facility failed to secure plan approval by the Department of Health prior to initiating renovations within the facility.

28 Pa Code 51.3. Notification (d)



 Plan of Correction - To be completed: 03/13/2019

Bureau of Licensure & Certification Division of safety inspection has been notified on February 2, 2019 of ongoing work at the facility. Administrator and Corporate Director of Operations were instructed to put together a list containing floor plans, finish schedule and specification sheets for all the materials being used for this update.

All areas have been identified as potentially being affected.

Contact has been made with a state plan reviewer. A plan review has been submitted to the Department of Facilities and Licensing through the online portal, on February 12, 2019. The Division of Safety Inspection, Department of Health will be contacted prior to future modifications or renovations.

Any further work will need prior approval from Corp Director of operations. Bi-weekly On-site visits by Marquis Healthcare Corporate Director of operations will be in effect until work completed at the facility to ensure compliance.

Date of Compliance: 3/13/19

NFPA 101 STANDARD Building Construction Type and Height:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain the building construction's fire resistive rating, affecting 2 of 2 levels within the facility.

Findings include:

1. Observations made on January 30, 2019, between 8:00 am and 3:00 pm, revealed rated ceiling assembly recessed light fixtures and ceiling diffusers were broken, missing or incomplete throughout the 1st and 2nd levels.

Interview at the exit conference with the Administrator, Regional Director of Plant Operations and the Maintenance Supervisor on January 30, 2019, at 2:50 pm, confirmed the incomplete rated ceiling assembly.









 Plan of Correction - To be completed: 03/13/2019

Nursing facility regional director of operations reached out to Pennsylvania Department of Health Healthcare Facilities and Licensing division on Friday February 8, 2019 and spoke with a state plan reviewer. Plans with scope of work together with floor plans, finish schedule and specification sheets for all the materials being used for this update have been sent to the Pennsylvania department of health division of licensing utilizing their online portal.

All areas have been identified as potentially being affected.

A full house audit will be done to ensure proper rated ceiling assembly, recessed light fixtures, and ceiling diffusers are all properly installed.
A small portion of the building is 1-Story with the remainder 2-stories. The fire rating in the 1-Story section is achieved by the existing construction (2 layers of sheetrock). This existing construction is not being modified. The fire rating in the floor assembly for the 2-Story section is achieved by UL-G265. The cosmetic work being done will maintain the fire rating. All work being done, is currently in the process of being uploaded to the Healthcare Facilities and Licensing's porthole for their review.


Random audits will be conducted by the Maintenance Director or designee to assure compliance weekly for 4 weeks followed by Monthly audits for 3 months.
Results will be reviewed at our QAPI meeting

Date of Compliance: 3/13/19
NFPA 101 STANDARD Egress Doors:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0222

Based on observation and interview, it was determined the facility failed to ensure egress doors with delayed-egress locking systems had required signage displayed on the doors, affecting 1 of 2 levels within the facility.
Findings include:

1. Observation made on January 30, 2019, at 1:35 pm, 1st floor, revealed in the corridor near resident room # 114, the delayed-egress door to the public way lacked the required signage that states:

"PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS "

Interview at the exit conference with the Administrator, Regional Director of Plant Operations and the Maintenance Supervisor on January 30, 2019, at 2:50 pm, confirmed the door lacked the required signage.








 Plan of Correction - To be completed: 03/13/2019

A delayed egress door sign stating "PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS" has been placed.

All delayed egress doors have been identified as potentially being affected.

All exit doors with delayed egress access will be checked to assure proper signage.

Random audits will be conducted by the Maintenance Director or designee to assure compliance weekly for 4 weeks followed by Monthly audits for 3 months.
Results will be reviewed at our QAPI meeting.

Date of Compliance: 3/13/19

NFPA 101 STANDARD Cooking Facilities:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on observation and interview, it was determined the facility failed to ensure that required signage was posted for portable K-type fire extinguishers, affecting 1 of 6 smoke zones within the facility.

Findings include:

1. Observation made on January 30, 2019 at 1:40 pm, revealed inside the 1st floor main kitchen, there was no placard posted in the vicinity of the wall mounted portable K-type fire extinguisher that states "The fire protection system shall be activated prior to using the fire extinguisher."

Interview at the exit conference with the Administrator, Regional Director of Plant Operations and the Maintenance Supervisor on January 30, 2019, at 2:50 pm, confirmed the required signage was not posted.






 Plan of Correction - To be completed: 03/13/2019

A sign stating "The Fire Protection system shall be activated prior to using the fire extinguisher" has been placed at the K-type extinguisher.

No other areas have been identified as potentially being affected.

Dietary staff will be in-serviced on proper signage at all times, as well as activating the fire protection prior to using the fire extinguisher.

Random audits will be conducted by the Maintenance Director or designee to assure proper signage in place, for 4 weeks followed by Monthly audits for 3 months.
Results will be reviewed at our QAPI meeting.

Date of Compliance: 3/13/19
NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on document review and interview, it was determined the facility failed to inspect the fire alarm system, affecting 1 of 2 required annual fire alarm inspections.

Findings include:

1. Document review on January 30, 2019, at 8:00 am, revealed the facility did not perform a fire alarm semi-annual visual inspection within the required timeframe.

Interview at the exit conference with the Administrator, Regional Director of Plant Operations and the Maintenance Supervisor on January 30, 2019, at 2:50 pm, confirmed a fire alarm semi-annual visual inspection had not been performed within the required timeframe.





 Plan of Correction - To be completed: 03/13/2019

The Semi-Annual Fire Alarm visual inspection was done December 4th 2018.

No other areas have been identified as potentially being affected.

Administrator and Maintenance director confirmed Semi Annual dates for 2019 Fire Alarm System Inspection, they are set for June and December 5, 2019.

Dates for upcoming testing have been logged in Administrators and Maintenance calendars with notice to call and confirm dates.
Alarm tests will be brought to QAPI Meeting.

Date of Compliance: 3/13/19
NFPA 101 STANDARD Smoke Detection:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Smoke Detection
2012 EXISTING
Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1.
19.3.4.5.2
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0347

Based on observation and interview, it was determined the facility failed to maintain smoke detectors which could delay activation of the fire alarm, affecting 2 of 6 smoke zones within the facility.

Findings include:

1. Observation made on January 30, 2019 at 1:05 pm, 1st floor, revealed a broken ceiling tile near a smoke detector inside the elevator machine room, which may allow smoke to enter above the ceiling assembly.

Interview at the exit conference with the Administrator, Regional Director of Plant Operations and the Maintenance Supervisor on January 30, 2019, at 2:50 pm, confirmed the broken ceiling tile.


2. Observation made on January 30, 2019 at 2:21 pm, 2nd floor, revealed a smoke detector was dislodged from the ceiling, inside resident room # 220.

Interview at the exit conference with the Administrator, Regional Director of Plant Operations and the Maintenance Supervisor on January 30, 2019, at 2:50 pm, confirmed a smoke detector was dislodged from the ceiling.





 Plan of Correction - To be completed: 03/13/2019

The broken ceiling tile in elevator mechanical room has been replaced with a Fire rated ceiling tile.
The dislodged smoke detector inside room #220 has been reconnected and tested.

All other areas have been identified as potentially being affected.

Maintenance Director or Designee will complete a full house audit, to ensure no broken ceiling tiles and all smoke detectors are intact.

Random audits will be completed weekly for 4 weeks followed by monthly audits for 3 months to ensure compliance.
Results will be brought to QAPI Meeting.

Date of Compliance: 3/13/19
NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
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
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on observation, document review and interview, it was determined the facility failed to inspect and maintain the automatic sprinkler system, affecting the entire facility.

Findings include:

1. Document review on January 30, 2019, at 8:00 am, revealed the facility could not produce a quarterly sprinkler inspection report for the 4th quarter of 2018.

Interview at the exit conference with the Administrator, Regional Director of Plant Operations and the Maintenance Supervisor on January 30, 2019, at 2:50 pm, confirmed a sprinkler inspection for the 4th quarter of 2018 had not been performed.


2. Document review on January 30, 2019, at 8:00 am, revealed the facility could not produce documentation that a sprinkler system obstruction inspection had been performed within the previous 5 years.

Interview at the exit conference with the Administrator, Regional Director of Plant Operations and the Maintenance Supervisor on January 30, 2019, at 2:50 pm, confirmed the documentation was not available.


3. Observations made on January 30, 2019 between 1:28 pm and 2:14 pm, revealed sprinklers with missing escutcheons in the following locations:

a. 1:28 pm, 1st floor resident room # 107, two missing escutcheons;
b. 1:35 pm, 1st floor resident room # 114, one missing escutcheon;
c. 2:05 pm, 1st floor resident room # 125, one missing escutcheon;
d. 2:07 pm, 1st floor resident room # 130, one missing escutcheon;
e. 2:14 pm, 2nd floor resident room # 226, one missing escutcheon.

Interview at the exit conference with the Administrator, Regional Director of Plant Operations and the Maintenance Supervisor on January 30, 2019, at 2:50 pm, confirmed the missing sprinkler escutcheons, in the above named locations.


4. Observation made on January 30, 2019 at 2:17 pm, revealed in the 2nd floor corridor near the beauty shop there was a concealed sprinkler with a missing cover plate.

Interview at the exit conference with the Administrator, Regional Director of Plant Operations and the Maintenance Supervisor on January 30, 2019, at 2:50 pm, confirmed the sprinkler was missing a cover plate.





 Plan of Correction - To be completed: 03/13/2019

An Annual sprinkler inspection was completed on February 7, 2019 with no issues noted.
Administrator and Maintenance Director reached out to new vendor Kissler Obrian, a quote is being obtained for the 5 year Obstruction Test.
Missing sprinkler escutcheons in rooms, 107, 114, 125, 130, 226 have been replaced.
The Sprinkler cover plate near the beauty shop has been replaced.

All areas have been identified as potentially being affected.

A 5 Year sprinkler Obstruction test will be completed. Results will be reviewed at QAPI meeting.
Administrator and Maintenance Director reached out to Vendor and secured our Quarterly sprinkler inspection for 2019. Dates have been placed in calendar with reminder.
A full house audit will be done to ensure no missing escutcheons and proper sprinkler plates are in place where required.
Random sprinkler Audits will be done to ensure escutcheons are properly secured, and cover plates in place where required. weekly for 4 weeks followed by monthly for 3 months.

Results of the Quarterly Sprinkler and 5 year obstruction test will be reviewed at QAPI meeting.
Results of the Sprinkler Escutcheons, and sprinkler cover plates audits will be brought to QAPI meeting .

Date of Compliance: 3/13/19

NFPA 101 STANDARD Portable Fire Extinguishers:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
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
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355

Based on observation and interview, it was determined the facility failed to ensure that portable fire extinguishers were inspected, affecting 1 of 6 smoke zones within the facility.

Findings include:

1. Observation made on January 30, 2019 at 1:46 pm, 1st floor, revealed the fire extinguisher in the corridor next to the maintenance office was missing a monthly quick-check inspection for December 2018.

Interview at the exit conference with the Administrator, Regional Director of Plant Operations and the Maintenance Supervisor on January 30, 2019, at 2:50 pm, confirmed the monthly quick-check was missed.





 Plan of Correction - To be completed: 03/13/2019

The fire extinguisher located near the maintenance shop has been inspected and tagged correctly.

All areas have been identified as potentially being affected.

A full house audit will be done to ensure all portable Fire extinguisher's monthly quick check was completed.

Random audits will be completed by the Maintenance Director or designee weekly for 4 weeks followed by Monthly for 3 months to ensure compliance. Results will be reviewed at Monthly QAPI meeting.

Date of Compliance: 3/13/19
NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to ensure smoke barrier walls were free of unsealed penetrations, affecting 2 of 6 smoke zones within the facility.

Findings include:

1. Observation made on January 30, 2019, at 1:20 pm, 1st floor, revealed above the ceiling of the smoke barrier double doors near the Director of Care Delivery Office, there was an unsealed penetration in the smoke barrier wall around an armor conduit.

Interview at the exit conference with the Administrator, Regional Director of Plant Operations and the Maintenance Supervisor on January 30, 2019, at 2:50 pm, confirmed the unsealed penetration.






 Plan of Correction - To be completed: 03/13/2019

The unsealed penetration in the smoke barrier wall around the armor conduit near the director of care delivery office has been sealed with UL 3M fire protection system CP 25WB+, System number W-L-7222

No other areas have been identified as potentially being affected.

An audit on all smoke barrier double doors ceilings will be done to ensure all smoke barrier walls have no penetration.

Random audits will be completed by the Maintenance Director or designee weekly for 4 weeks followed by Monthly for 3 months to ensure no penetration through smoke barrier double door ceiling walls.

Date of Compliance: 3/13/19
NFPA 101 STANDARD HVAC:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0521

Based on document review and interview, it was determined the facility failed to ensure fire dampers were exercised within the required timeframe, affecting the entire facility.

Findings include:

1. Document review on January 30, 2019, at 8:00 am, revealed the facility could not provide documentation the facility's fire dampers had been exercised since October 20, 2014.

Interview at the exit conference with the Administrator, Regional Director of Plant Operations and the Maintenance Supervisor on January 30, 2019, at 2:50 pm, confirmed the documentation was not available.










 Plan of Correction - To be completed: 03/13/2019

Administrator and Maintenance Director reached out to vendor to secure date for Fire Damper Inspection.

All areas have been identified as potentially being affected.

A Fire damper inspection will be initiated on February 19, 2019.

A new 4 year Fire Damper Inspection will be added to TELS (facility punch list)

Date of Compliance: 3/13/19
NFPA 101 STANDARD HVAC - Any Heating Device:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
HVAC - Any Heating Device
Any heating device, other than a central heating plant, is designed and installed so combustible materials cannot be ignited by device, and has a safety feature to stop fuel and shut down equipment if there is excessive temperature or ignition failure. If fuel fired, the device also:
* is chimney or vent connected.
* takes air for combustion from outside.
* provides for a combustion system separate from occupied area atmosphere.
19.5.2.2
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0522

Based on observation and interview, it was determined the facility failed to maintain heating units were free of combustible materials, affecting 1 of 6 smoke zones within the facility.

Findings include:

1. Observation made on January 30, 2019, at 1:29 pm, revealed inside 1st floor resident room # 107, combustible clothing and paper items were stored against a heater unit.

Interview at the exit conference with the Administrator, Regional Director of Plant Operations and the Maintenance Supervisor on January 30, 2019, at 2:50 pm, confirmed combustibles were being stored against a heater unit.








 Plan of Correction - To be completed: 03/13/2019

All combustible clothing and items being stored near the heater in room #107 have been removed.

All resident rooms have been checked to assure no combustible items near heaters.

A full house audit will be done to ensure no combustible items stored near heater units.
Staff will be in-serviced to assure all combustible items, clothes are not being kept near any heater units.

Random Audits will be completed to ensure compliance, weekly for 4 weeks followed by monthly for 3 months.

Date of Compliance: 3/13/19
NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to ensure medical gas cylinders were properly secured, affecting 1 of 6 smoke zones within the facility.

Findings include:

1. Observation made on January 30, 2019, at 1:52 pm, revealed inside the 1st floor oxygen manifold room, there were 3 unsecured K Type oxygen cylinders.

Interview at the exit conference with the Administrator, Regional Director of Plant Operations and the Maintenance Supervisor on January 30, 2019, at 2:50 pm, confirmed the oxygen cylinders were not secured.






 Plan of Correction - To be completed: 03/13/2019

The 3 unsecured K type oxygen cylinders have been secured.

There are no other K type oxygen cylinder at the facility.

Maintenance, housekeeping, & respiratory therapist staff will be in-serviced on securing type K oxygen tanks.

Random Audits will be completed by maintenance director or designee to ensure compliance, weekly for 4 weeks followed by monthly for 3 months

Date of Compliance: 3/13/19
NFPA 101 STANDARD Gas Equipment - Liguid Oxygen Equipment:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Gas Equipment - Liquid Oxygen Equipment
The storage and use of liquid oxygen in base reservoir containers and portable containers comply with sections 11.7.2 through 11.7.4 (NFPA 99).
11.7 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0930

Based on observation and interview, it was determined the facility failed to ensure liquid oxygen cylinders were properly restrained, affecting 1 of 6 smoke zones within the facility.

Findings include:

1. Observation made on January 30, 2019 at 1:53 pm, revealed inside the 1st floor oxygen manifold room, there were 2 unrestrained liquid oxygen cylinders.

Interview at the exit conference with the Administrator, Regional Director of Plant Operations and the Maintenance Supervisor on January 30, 2019, at 2:50 pm, confirmed the liquid oxygen cylinders were not restrained.





 Plan of Correction - To be completed: 03/13/2019

The 2 unrestrained liquid oxygen cylinders have been restrained.

There are no other Liquid oxygen cylinders in the facility.

Maintenance, housekeeping and respiratory therapist staff will be in-serviced on restraining liquid oxygen cylinders.

Random Audits will be completed by maintenance director or designee to ensure compliance, weekly for 4 weeks followed by monthly for 3 months.

Date of Compliance: 3/13/19

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