Nursing Investigation Results -

Pennsylvania Department of Health
JUNIPER VILLAGE AT BROOKLINE-REHABILITATION AND SKILLED CARE
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
JUNIPER VILLAGE AT BROOKLINE-REHABILITATION AND SKILLED CARE
Inspection Results For:

There are  27 surveys for this facility. Please select a date to view the survey results.

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JUNIPER VILLAGE AT BROOKLINE-REHABILITATION AND SKILLED CARE - 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 February 22, 2019, at Juniper Village at Brookline-Rehabilitation and Skilled Care, 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# 281302
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 22, 2019, it was determined that Juniper Village at Brookline-Rehabilitation and Skilled Care, was not in compliance with the following requirements of the Life Safety Code for an existing 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 three story, Type II (000), unprotected, noncombustible building, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height: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.
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 building construction type.

Findings include:

1. Observation on February 22, 2019, revealed the building story height is greater than the maximum allowable height by one story.

Exit interview with the facility administrator and the facilities manager on February 22, 2019, between 12:15 p.m. and 12:30 p.m., confirmed the building exceeds the maximum allowable story height.





 Plan of Correction - To be completed: 04/01/2019

The facility has requested a new FSES be conducted under the 2012 Life Safety Code guidelines. The facility has requested a five year waiver for construction type. Contractors currently working on remodeling plans with construction scheduled to being in 2020. Deficient areas/structure to be managed at that time.
NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
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




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain one exit stair tower enclosure, affecting three of nine smoke compartments.

Findings include:

1. Observation on February 22, 2019, at 9:45 a.m., revealed the west stair tower enclosure, lacked required one-hour, fire resistive integrity in one location (unenclosed around structural steel beam).

Exit interview with the facility administrator and the facilities manager on February 22, 2019, between 12:15 p.m. and 12:30 p.m., confirmed the stair tower enclosure deficiency.





 Plan of Correction - To be completed: 04/01/2019

The identified penetration will be sealed with approved stop gap penetration system. Regular rounds of the building will be conducted in order to identify and correct any penetrations with an approved stop gap penetration system. The Environmental Services Director or designee will be responsible for this process.
NFPA 101 STANDARD Vertical Openings - Enclosure: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.
Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0311

Based on observation and interview, it was determined the facility failed to construct and maintain one vertical opening, affecting one of three floors.

Findings include:

1. Observation on February 22, 2019, at 9:20 a.m., revealed the dishwasher exhaust shaft was unenclosed within the attic spaces.

Exit interview with the facility administrator and the facilities manager on February 22, 2019, between 12:15 p.m. and 12:30 p.m., confirmed the vertical opening deficiency.





 Plan of Correction - To be completed: 04/01/2019

A contracted company will be contacted to evaluate and complete necessary work for appropriate exhaust shaft construction.
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 documentation review and interview, it was determined the facility failed to maintain cooking facilities, affecting one of nine smoke compartments.

Findings include:

1. Observation on February 22, 2019, at 11:35 a.m., revealed the facility lacked two of two required kitchen suppression system inspections.

Exit interview with the facility administrator and the facilities manager on February 22, 2019, between 12:15 p.m. and 12:30 p.m., confirmed the cooking facilities deficiencies.





 Plan of Correction - To be completed: 04/01/2019

Inspection for the semi-annual inspection/cleaning of the exhaust hood occurred on 3/12/2018 and 9/11/2018. Next cleaning is scheduled for 3/2019. The Environmental Services Director or designee will be responsible for coordinating this semi-annual inspection/cleaning of the exhaust hood.
NFPA 101 STANDARD Alcohol Based Hand Rub Dispenser (ABHR):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.
Alcohol Based Hand Rub Dispenser (ABHR)
ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met:
* Corridor is at least 6 feet wide
* Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols
* Dispensers shall have a minimum of 4-foot horizontal spacing
* Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room
* Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30
* Dispensers are not installed within 1 inch of an ignition source
* Dispensers over carpeted floors are in sprinklered smoke compartments
* ABHR does not exceed 95 percent alcohol
* Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11)
* ABHR is protected against inappropriate access
18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0325

Based on observation and interview, it was determined the facility failed to install and maintain alcohol-based hand rub (ABHR) stations in multiple locations, affecting six of nine smoke compartments.

Findings include:

1. Observation on February 22, 2019, between 9:10 a.m. and 10:30 a.m., revealed trash cans in resident rooms were installed beneath ABHR stations at the third and second floor levels.

Exit interview with the facility administrator and the facilities manager on February 22, 2019, between 12:15 p.m. and 12:30 p.m., confirmed the ABHR station deficiencies.





 Plan of Correction - To be completed: 04/01/2019

All resident metal lidded laundry hampers have been moved from under installed ABHR stations in resident rooms. The environmental services director or designee will ensure compliance of no placement of items under ABHR stations in resident rooms.
NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
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 documentation review and interview, it was determined the facility failed to maintain the building fire alarm system, affecting nine of nine smoke compartments.

Findings include:

1. Observation on February 22, 2019, at 11:30 a.m., revealed the facility lacked a semi-annual visual fire alarm inspection, as well as a current, biennial smoke detector sensitivity inspection.

Exit interview with the facility administrator and the facilities manager on February 22, 2019, between 12:15 p.m. and 12:30 p.m., confirmed the building fire alarm system deficiency.







 Plan of Correction - To be completed: 04/01/2019

Facility records show smoke detector sensitivity checks held on 1/15/18 and 7/13/18. Fire alarm inspection services completed 1/23/19-1/24/19 and 4/17/18. The environmental services director or designee will monitor the system regularly, to ensure proper operation, and notify the contracted vendor in the event repairs of necessary outside of routine checks/inspections.
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 and interview, it was determined the facility failed to maintain the automatic sprinkler system in multiple instances, affecting nine of nine smoke compartments.

Findings include:

1. Observation on February 22, 2019, between 8:55 a.m. and 11:25 a.m., revealed the following:
a. 8:55 a.m. A transfer grill was located within the third floor ceiling assembly in the Living Room.
b. 11:00 a.m. An escutcheon plate was missing from a sprinkler head assembly within the first floor, PT.
c. 11:25 a.m. The facility lacked automatic sprinkler system testing and inspection data for the last four quarters.

Exit interview with the facility administrator and the facilities manager on February 22, 2019, between 12:15 p.m. and 12:30 p.m., confirmed the automatic sprinkler system deficiencies.




 Plan of Correction - To be completed: 04/01/2019

Transfer grill was replaced in Living Room and escutcheon plate was installed in first floor PT.
Facility records show automatic sprinkler system testing was completed 10/2018, 7/2018, 4/2018, and 1/2018.
Environmental Services director or designee will be responsible for maintaining documentation of quarterly sprinkler system testing.
NFPA 101 STANDARD Corridor - 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.
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.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain three corridor openings, affecting three of nine smoke compartments.

Findings include:

1. Observation on February 22, 2019, between 9:11 a.m. and 10:22 a.m., revealed the following:

a. 9:11 a.m. The third floor, Pantry, lacked positive latching.
b. 10:12 a.m. The second floor, resident room 221, lacked smoke-tight integrity.
c. 10:22 a.m. The first floor, Dietary doors, required adjustment in order to fully close and latch.

Exit interview with the facility administrator and the facilities manager on February 22, 2019 between 12:15 p.m. and 12:30 p.m., confirmed the corridor opening deficiencies.





 Plan of Correction - To be completed: 04/01/2019

Positive latching has been ordered for third flood pantry door.
Resident room 221 door has been ordered.
Dietary doors have been ordered.

Environmental Services director or designee to install the above listed items once arrived at facility to maintain protection in corridor areas.
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 observation and interview, it was determined the facility failed to maintain heating, ventilation, and air conditioning, in multiple locations, affecting three of three floors.

Findings include:

1. Observation on February 22, 2019, between 10:20 a.m. and 11:45 a.m., revealed the following:
a. 10:20 a.m.-10:40 a.m. Resident room exhaust duct work lacked fire dampers and access panels in multiple locations between the second and third floors.
b. 11:45 a.m. The facility lacked the required four-year, fire damper preventive maintenance documentation.

Exit interview with the facility administrator and the facilities manager on February 22, 2019, between 12:15 p.m. and 12:30 p.m., confirmed the HVAC deficiencies.




 Plan of Correction - To be completed: 04/01/2019

All resident room duct work between second and third floor will be checked to determine if fire dampers are in place and access panels will be created. Contracted company will be scheduled to complete required 4-year, fire damper preventive maintenance.
Environmental Services Director or designee will maintain necessary documentation to support preventative maintenance completion.
NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu: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.
Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0541

Based on observation and interview, it was determined the facility failed to maintain one soiled linen chute, affecting one of nine smoke compartments.

Findings include:

1. Observation on February 22, 2019, at 10:44 a.m., revealed the soiled linen chute termination room door, was held open by unapproved means (door chock).

Exit interview with the facility administrator and the facilities manager on February 22, 2019, between 12:15 p.m. and 12:30 p.m., confirmed the soiled linen chute deficiency.



 Plan of Correction - To be completed: 04/01/2019

The facility has corrected the soiled linen chute termination room door being held open by an unapproved means.
The environmental services director or designee will be responsible for monitoring of smoke compartments.
NFPA 101 STANDARD Fire Drills: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 Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to conduct two of twelve required fire drills.

Findings include:

1. Observation on February 22, 2019, at 11:20 a.m., revealed the facility lacked two of twelve required fire drills (first quarter, second shift, and fourth quarter, first shift).

Exit interview with the facility administrator and the facilities manager on February 22, 2019, between 12:15 p.m. and 12:30 p.m., confirmed the fire drill deficiency.






 Plan of Correction - To be completed: 04/01/2019

Environmental Services documentation showed completion of 12/12 fire drills for all four quarters, however drills were not completed within the quarter guidelines. Environmental Services will complete required fire drills of one drill per shift per quarter. The environmental services director or designee will be responsible for monitoring the scheduled fire drills.
NFPA 101 STANDARD Electrical Systems - 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.
Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0914

Based on documentation review and interview, it was determined the facility failed to maintain the generator set.

Findings include:

1. Observation on February 22, 2019, at 11:38 a.m., revealed the facility lacked required monthly, thirty minute, full load testing documentation, for the generator set and an annual load bank test.

Exit interview with the facility administrator and the facilities manager on February 22, 2019, between 12:15 p.m. and 12:30 p.m., confirmed the generator set deficiency.




 Plan of Correction - To be completed: 04/01/2019

The facility's contracted vendor has been contacted to conduct monthly, thirty minute, full load testing for the generator set. The annual load bank test was completed 2/2019.
The Environmental Services Director or designee will be responsible for maintaining necessary documentation of generator testing.
NFPA 101 STANDARD Gas Equipment - Labeling Equipment and Cylind: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 - Labeling Equipment and Cylinders
Equipment listed for use in oxygen-enriched atmospheres are so labeled. Oxygen metering equipment and pressure reducing regulators are labeled "OXYGEN-USE NO OIL." Flowmeters, pressure reducing regulators, and oxygen-dispensing apparatus are clearly and permanently labeled designating the gases for which they are intended. Oxygen-metering equipment, pressure reducing regulators, humidifiers, and nebulizers are labeled with name of manufacturer or supplier. Cylinders and containers are labeled in accordance with CGA C-7. Color coding is not utilized as the primary method of determining cylinder or container contents. All labeling is durable and withstands cleaning or disinfecting.
11.5.3.1 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0928

Based on observation and interview, it was determined the facility failed to maintain gas equipment labeling in two locations.

Findings include:

1. Observation on February 22, 2019, between 9:31 a.m. and 9:35 a.m., revealed oxygen shut-off valves located at the third floor level, lacked proper labeling.

Exit interview with the facility administrator and the facilities manager on February 22, 2019, between 12:15 p.m. and 12:30 p.m., confirmed the gas equipment labeling deficiency.



 Plan of Correction - To be completed: 04/01/2019

Facility had labeling of shut-off valves on the valve. Labeling also placed on outside cover. Environmental Services director or designee will monitor and maintain integrity of labels.

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