Nursing Investigation Results -

Pennsylvania Department of Health
NORTHAMPTON COUNTY HOME- GRACEDALE
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
NORTHAMPTON COUNTY HOME- GRACEDALE
Inspection Results For:

There are  57 surveys for this facility. Please select a date to view the survey results.

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NORTHAMPTON COUNTY HOME- GRACEDALE - 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 January 22-23, 2020, at Northampton County Home-Gracedale, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.




 Plan of Correction:


Initial comments:Name: NORTHWEST WING - Component: 01 - Tag: 0000


Facility ID# 072802
Component 01
Building 01
Northwest Wing

Based on a Medicare/Medicaid Recertification Survey completed January 22-23, 2020, it was determined that Northapton County Home-Gracedale, 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 two story, Type III (200), unprotected ordinary building, with a basement, basement-level crawl space, and an unused attic, that is fully sprinklered.







 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies - Contiguous Non-Health: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.
Multiple Occupancies - Contiguous Non-Health Care Occupancies
Non-health care occupancies that are located immediately next to a Health Care Occupancy, but are primarily intended to provide outpatient services are permitted to be classified as Business or Ambulatory Health Care Occupancies, provided the facilities are separated by construction having not less than 2-hour fire resistance-rated construction, and are not intended to provide services simultaneously for four or more inpatients. Outpatient surgical departments must be classified as Ambulatory Health Care Occupancy regardless of the number of patients served.
18.1.3.4.1, 19.1.3.4.1
Observations:
Name: NORTHWEST WING - Component: 01 - Tag: 0132

Based on observation and interview, it was determined the facility failed to maintain one common wall on one floor, affecting one of three floors.

Findings include:

1. Observation on January 23, 2020, at 8:22 a.m., revealed the common wall doors with the 02 Component (doors 43 and 44) required adjustment to fully latch one to another.

Exit interview with the facility administrator and the facilities manager on January 23, 2020, between 11:00 a.m. and 11:30 a.m., confirmed the common wall door deficiency.


 Plan of Correction - To be completed: 03/20/2020

Latch on door 43 and 44 to be adjusted to ensure proper operation. Maintenance staff will be re-educated in identifying door latch malfunctions as part of daily routine. Maintenance Director/designee to report repair findings at monthly QAPI steering committee meetings.
NFPA 101 STANDARD Building Construction Type and Height: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.
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: NORTHWEST WING - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements on three of three floors.

Findings include:

1. Observation on January 23, 2020, between 8:00 a.m. and 11:00 a.m., revealed the facility exceeded the maximum allowable story height for the type of construction.

Exit interview with the facility administrator and the facilities manager on January 23, 2020, between 11:00 a.m. and 11:30 a.m., confirmed the facility exceeded the maximum allowable story height for an unprotected ordinary, type of building construction.


 Plan of Correction - To be completed: 02/10/2020

Request for continuation of FSES.
NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
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: NORTHWEST WING - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain smoke barrier separation walls in two locations, affecting one of three floors.

Findings include:

1. Observation on January 23, 2020, between 8:00 a.m. and 11:00 a.m., revealed the two second floor smoke barrier separation walls did not extend through the attic spaces to the roof assembly.

Exit interview with the facility administrator and the facilities manager on January 23, 2020, between 11:00 a.m. and 11:30 a.m., confirmed the smoke barrier wall deficiencies.


 Plan of Correction - To be completed: 02/10/2020

Request for continuation of FSES.
NFPA 101 STANDARD Smoking Regulations: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.
Smoking Regulations
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4

Observations:
Name: NORTHWEST WING - Component: 01 - Tag: 0741

Based on observation and interview, it was determined the facility failed to maintain smoking regulations in one location, affecting one of three floors.

Findings include:

1. Observation on January 23, 2020, at 9:22 a.m., revealed cigarette butts were located within a trash receptacle at the door 14 exit discharge location. This is also not an authorized smoking area.

Exit interview with the facility administrator and the facilities manager on January 23, 2020, between 11:00 a.m. and 11:30 a.m., confirmed the smoking regulations deficiency.




 Plan of Correction - To be completed: 03/20/2020

No smoking sign will be placed on the door.
All Staff will be re-educated regarding facility smoking policy and designated smoking areas.
Area will be monitored by Housekeeping Supervisors or designee of evidence of non-compliance.
Variances will be discussed by QAPI steering committee to review need for further action.
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: NORTHWEST WING - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain medical gas cylinder storage in one location, affecting one of three floors.

Findings include:

1. Observation on January 23, 2020, at 8:44 a.m., revealed an unsecured oxygen "e" cylinder within first floor Linen Room 40.

Exit interview with the facility administrator and the facilities manager on January 23, 2020, between 11:00 a.m. and 11:30 a.m., confirmed the medical gas cylinder storage deficiency.




 Plan of Correction - To be completed: 03/20/2020

Oxygen tank was properly secured.
Re-education will be provided to Nursing Staff of proper storage of oxygen tanks.
Storage will be monitored by Nursing staff on routine shift rounds as well as by designed Supervisors on monthly environmental rounds of all units.
Results of Audits will be reviewed at the QAPI steering meeting.
Initial comments:Name: MAIN BUILDING - Component: 02 - Tag: 0000


Facility ID# 072802
Component 02
Building 02
Main Building

Based on a Medicare/Medicaid Recertification Survey completed January 22-23, 2020, it was determined that Northampton County Home-Gracedale, 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 two story, Type II (222), fire resistive building, with a basement, basement-level crawl space, penthouse, and an unused attic, that is fully sprinklered.


 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies - Contiguous Non-Health: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.
Multiple Occupancies - Contiguous Non-Health Care Occupancies
Non-health care occupancies that are located immediately next to a Health Care Occupancy, but are primarily intended to provide outpatient services are permitted to be classified as Business or Ambulatory Health Care Occupancies, provided the facilities are separated by construction having not less than 2-hour fire resistance-rated construction, and are not intended to provide services simultaneously for four or more inpatients. Outpatient surgical departments must be classified as Ambulatory Health Care Occupancy regardless of the number of patients served.
18.1.3.4.1, 19.1.3.4.1
Observations:
Name: MAIN BUILDING - Component: 02 - Tag: 0132

Based on observation and interview, it was determined the facility failed to maintain two common walls, affecting two of three floors.

Findings include:

1. Observation on January 22, 2020, between 11:20 a.m. and 2:01 p.m., revealed the following:

a. 11:20 a.m., the second floor, northwest common wall door labels were painted over.
b. 2:01 p.m., the first floor, Laundry Building doors did not fully latch.

Exit interview with the facility administrator and the facilities manager on January 23, 2020, between 11:00 a.m. and 11:30 a.m., confirmed the common wall deficiencies.



 Plan of Correction - To be completed: 03/20/2020

a. Paint will be removed from northwest common wall door label.
Maintenance staff will be re-educated regarding painting of door frames.
b. Building door latch will be adjusted properly to ensure proper closure.
Will re-educate Maintenance staff on identifying proper latching of the various styles in the building.
All staff will be educated by memo on proper submission of how to report if a door is not latching correctly.
Maintenance Director/designee to report repair findings at monthly QAPI steering committee meetings.
NFPA 101 STANDARD Building Construction Type and Height: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.
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 - Component: 02 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements in five locations, affecting two of three floors.

Findings include:

1. Observation on January 22, 2020, between 10:33 a.m. and 11:48 a.m., revealed the following:

a. 10:33 a.m., construction plastic materials were located within the crawl space area adjacent to the number six elevator at the basement level.
b. 10:50 a.m., combustible foam insulating materials at the floor level, within the penthouse-level elevator machine room.
c. 10:55 a.m., combustible foam insulating materials at the roof level within the attic loft area.
d. 11:30 a.m., wood paneling covered approximately 40 percent of the walls within the second floor Speech and Hearing Office.
e. 11:48 a.m., spray fireproofing was lacking in one location within the kitchen penthouse (beam).

Exit interview with the facility administrator and the facilities manager on January 23, 2020, between 11:00 a.m. and 11:30 a.m., confirmed the building construction deficiencies.



 Plan of Correction - To be completed: 03/20/2020

a. Construction material removed from the area. Education issued to Maintenance staff on proper storage.
b. Material was removed from identifying areas and replaced with 3M CP25WB+ Fire Barrier Sealant.
c. Tech Data Sheet has been placed with Plan of Correction for foam insulation used by contractor.
d. Paneling is scheduled to be removed from the south wall. Will replace with 5/8 sheetrock and finishing.
e. will contract Safeway Environmental to apply fire proofing material to area as needed.
Maintenance Supervisor/designee will review progress and variances with the QAPI steering committee.
NFPA 101 STANDARD Discharge from Exits: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.
Discharge from Exits
Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface.
18.2.7, 19.2.7
Observations:
Name: MAIN BUILDING - Component: 02 - Tag: 0271

Based on observation and interview, it was determined the facility failed to maintain discharge from exits in one location, affecting one of three floors.

Findings include:

1. Observation on January 22, 2020, at 10:27 a.m., revealed the aisle to the basement-level exit discharge door, located within the dietary electric room, was not maintained.

Exit interview with the facility administrator and the facilities manager on January 23, 2020, between 11:00 a.m. and 11:30 a.m., confirmed the exit discharge deficiency.



 Plan of Correction - To be completed: 03/20/2020

Area was freed of any unnecessary items which may impede access to the door.
Maintenance staff will be re-educated regarding required aisle clearances.
Preventative maintenance will be performed monthly to ensure compliance.
Maintenance Supervisor or designee will report variances or concerns to QAPI steering committee.

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 - Component: 02 - Tag: 0311

Based on observation and interview, it was determined the facility failed to maintain vertical openings in two locations, affecting three of three floors.

Findings include:

1. Observation on January 22, 2020, between 10:00 a.m. and 1:00 p.m., revealed expansion joints at the first and second floor levels did not provide the required two-hour, fire resistive rating.

2. Observation on January 22, 2020, between 12:38 p.m. and 1:20 p.m., revealed the following:

a. 12:38 p.m., a penetration of the floor slab assembly within the duct enclosure within SW126.
b. 1:20 p.m., vision panels within the first floor chapel doors lacked rated glass.

Exit interview with the facility administrator and the facilities manager on January 23, 2020, between 11:00 a.m. and 11:30 a.m., confirmed the vertical openings deficiencies.



 Plan of Correction - To be completed: 03/20/2020

1. Request continuation of FSES.

2.a. etrations will be sealed with 3M CP25W+ Fire Barrier Sealant.
Maintenance Staff will be re-educated to be vigilant when working in hidden areas to identify compromised fire barriers and to rectify identified areas.
b. Outside vendor will be contacted to ensure properly rated glass is installed in the first floor chapel doors.
Variances will be reported to administrator and reviewed with the QAPI steering committee.
NFPA 101 STANDARD Hazardous Areas - 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.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: MAIN BUILDING - Component: 02 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures in four locations, affecting one of three floors.

Findings include:

1. Observation on January 22, 2020, between 11:05 a.m. and 1:27 p.m., revealed the following:

a. 11:05 a.m., carts blocked the NE2 Utility Room 1 door from closing.
b. 11:07 a.m., carts blocked the NE2 Utility Room 2 door from closing.
c. 1:25 a.m., carts blocked the SE2 Utility Room 1 door from closing.
d. 1:27 a.m., soiled linen was housed within the SE2 Shower Room.

Exit interview with the facility administrator and the facilities manager on January 23, 2020, between 11:00 a.m. and 11:30 a.m., confirmed the hazardous area enclosure deficiencies.


 Plan of Correction - To be completed: 03/20/2020

Items removed to proper storage areas, obstructed doorways cleared.
Nursing staff will be re-educated regarding proper storage and maintaining unobstructed doorways.
Storage and doorway clearance will be monitored by Nursing Staff on routine shift rounds as well as by designated supervisors on monthly environmental rounds of all units.
Variances will be reviewed by the QAPI steering committee with additional intervention/audits initiated as needed.
NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 - Component: 02 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in two locations, affecting one of three floors.

Findings include:

1. Observation on January 22, 2020, between 10:09 a.m. and 10:15 a.m., revealed the following:

a. the sprinkler box, located within the basement-level storeroom, lacked a wrench.
b. wiring was located atop branch sprinkler piping within the basement-level exit access corridor system, located closest to elevator number two.

Exit interview with the facility administrator and the facilities manager on January 23, 2020, between 11:00 a.m. and 11:30 a.m., confirmed the automatic sprinkler system deficiencies.


 Plan of Correction - To be completed: 03/20/2020

a. Wrench was installed in the sprinkler box. Quarterly preventative maintenance will be performed to inspect sprinkler boxes.
b. Wiring relocated and secured MC cable to not be in contact with sprinkler pipes.
Maintenance staff will be re-educated on the importance of running and placement of wires in ceiling.
Maintenance Supervisor or designee will report variances and progress during routine QAPI steering committee meetings.
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 - Component: 02 - Tag: 0355

Based on observation and interview, it was determined the facility failed to maintain one portable fire extinguisher, affecting one of three floors.

Findings include:

1. Observation on January 22, 2020, at 10:52 a.m., revealed a portable fire extinguisher resided on the ground within the penthouse-level elevator machine room.

Exit interview with the facility administrator and the facilities manager on January 23, 2020, between 11:00 a.m. and 11:30 a.m., confirmed the portable fire extinguisher deficiency.




 Plan of Correction - To be completed: 03/20/2020

Fire extinguisher was placed at proper height and mounted.
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 - Component: 02 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors on one of three floors.

Findings include:

1. Observation on January 23, 2020, at 9:09 a.m., revealed the SE-1, Room 4 corridor door lacked smoke-tight integrity.

Exit interview with the facility administrator and the facilities manager on January 23, 2020, between 11:00 a.m. and 11:30 a.m., confirmed the corridor opening deficiency.




 Plan of Correction - To be completed: 03/20/2020

Will install UL rated smoke blocking seal on door to seal gap.
Carpenter will review preventative maintenance's more closely on smoke blocking sealants of doors during scheduled maintenance.
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 - Component: 02 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain one smoke barrier separation wall, affecting one of three floors.

Findings include:

1. Observation on January 22, 2020, at 1:15 p.m., revealed two penetrations of the portion of the smoke barrier separation wall, located within the SE-2 Nurse's Station.

Exit interview with the facility administrator and the facilities manager on January 23, 2020, between 11:00 a.m. and 11:30 a.m., confirmed the smoke barrier separation wall deficiency.



 Plan of Correction - To be completed: 03/20/2020

Penetrations will be sealed with 3M CP25W+ Fire Barrier Sealant to ensure integrity of barrier is consistent.

NFPA 101 STANDARD Electrical Systems - Receptacles: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.
Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)
Observations:
Name: MAIN BUILDING - Component: 02 - Tag: 0912

Based on observation and interview, it was determined the facility failed to maintain the electrical system in one location, affecting one of three floors.

Findings include:

1. Observation on January 22, 2020, at 11:30 a.m., revealed a junction box cover lacking within the second floor exit access corridor, located closest to the Victorian Garden.

Exit interview with the facility administrator and the facilities manager on January 23, 2020, between 11:00 a.m. and 11:30 a.m., confirmed the electrical deficiency.



 Plan of Correction - To be completed: 03/20/2020

Cover to junction box will be installed and penetration will be sealed with 3M CP25WB+ Fire Barrier Sealant.
Maintenance personnel will be re-educated to be more mindful of replacing junction box covers and to correct penetrations.

Initial comments:Name: TOWER BUILDING - Component: 03 - Tag: 0000


Facility ID# 072802
Component 03
Building 03
Tower

Based on a Medicare/Medicaid Recertification Survey completed January 22-23, 2020, it was determined that Northampton County Home-Gracedale, 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 483.70(a).

This is a ten story, Type II (222), fire resistive building, with a basement and miscellaneous rooftop mechanical spaces, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
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: TOWER BUILDING - Component: 03 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements in one location, affecting one of eleven floors.

Findings include:

1. Observation on January 23, 2020, at 10:23 a.m., revealed structural steel lacked spray fireproofing within the basement-level, HVAC Office.

Exit interview with the facility administrator and the facilities manager on January 23, 2020, between 11:00 a.m. and 11:30 a.m., confirmed the building construction deficiency.




 Plan of Correction - To be completed: 03/20/2020

Safeway Environmental will be contacted to apply approved fire proofing on all untreated structural steel beams.
Maintenance Supervisor/designee will inspect further areas of concern and have fire proofing applied as necessary.
Variances will be reported to the administrator/QAPI steering committee meeting.
NFPA 101 STANDARD Stairways and Smokeproof Enclosures:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
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: TOWER BUILDING - Component: 03 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain the required fire resistance rating of stair towers on one of eleven floors.

Findings include:

1. Observation on January 22, 2020, at 11:30 a.m., revealed the Tower 8 stair door, on the 8th floor, did not latch in the frame when tested.

Exit interview with the facility administrator and the facilities manager on January 23, 2020, between 11:00 a.m. and 11:30 a.m., confirmed the door lacked positive latching.




 Plan of Correction - To be completed: 03/20/2020

Latch on Tower 8 stair door will be repaired properly to ensure appropriate operating condition. The door is slated for replacement as part of the door improvement initiative.
NFPA 101 STANDARD Hazardous Areas - Enclosure:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: TOWER BUILDING - Component: 03 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous areas on one of eleven floors.

Findings include:

1. Observation on January 23, 2020, at 8:30 a.m., revealed an open wiring penetration through the ceiling of the Green storage room on the 3rd floor.

Exit interview with the facility administrator and the facilities manager on January 23, 2020, between 11:00 a.m. and 11:30 a.m., confirmed the open wiring penetration.






 Plan of Correction - To be completed: 03/20/2020

Penetration will be sealed with 3M CP 25WP+ Fire Barrier Sealant to ensure integrity of barrier is consistent.
Maintenance crew re-educated of the importance of identifying penetrations and identifying proper remediation.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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: TOWER BUILDING - Component: 03 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the sprinkler system on four of eleven floors.

Findings include:

1. Observation on January 22, 2020, between 10:35 a.m. and 2:05 p.m., revealed the following:

a. At 10:35 a.m., the sprinkler in the laundry chute on the 10th floor was covered with debris.
b. At 11:55 a.m., there was an open 2-inch hole in the ceiling tile over the door to the staff lockers.
c. At 1:10 p.m., sprinkler in storage room NL471 on the 7th floor was obstructed by a surface-mounted light fixture.
d. At 1:15 p.m., sprinkler in the blue tub room, 7th floor, was obstructed by a surface- mounted ceiling light.
e. At 1:45 p.m., in room 6C2, a sprinkler escutcheon was missing near the resident bathroom.
f. At 2:05 p.m., in room 5C3, a sprinkler escutcheon was missing near the resident bathroom.

Exit interview with the facility administrator and the facilities manager on January 23, 2020, between 11:00 a.m. and 11:30 a.m., confirmed the sprinkler deficiences.


 Plan of Correction - To be completed: 03/20/2020

a. Sprinkler head in laundry chute cleaned. Sprinkler head was added to preventative maintenance.
b. Ceiling tile replaced with new tile.
c.& d. Light fixture moved to achieve proper clearance.
e. & f. Will install escutcheon at sprinklers where missing.


NFPA 101 STANDARD Portable Fire Extinguishers:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
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: TOWER BUILDING - Component: 03 - Tag: 0355

Based on observation and interview, it was determined the facility failed to maintain fire extinguishers on one of eleven floors.

Findings include;

1. Observation on January 23, 2020, at 10:00 a.m., revealed a fire extinguisher in the business office was being stored off it's hook and was obstructed by various items also being stored on top of a cabinet.

Exit interview with the facility administrator and the facilities manager on January 23, 2020, between 11:00 a.m. and 11:30 a.m., confirmed the extinguisher was not secured on a hook.




 Plan of Correction - To be completed: 03/20/2020

Fire extinguisher was mounted to appropriate bracket clearing any obstructions.
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: TOWER BUILDING - Component: 03 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors on six of eleven floors.

Findings include:

1. Observation on January 22, 2020, between 10:20 a.m. and 2:20 p.m., revealed the following;

a. At 10:20 a.m., room 10B 3 door T10-16 not smoke tight in the frame.
b. At 10:45a.m., room 10 D 1 door T10-31 not smoke tight in the frame.
c. At 10:50 a.m., room 10 C 3 door T10-26 not smoke tight in the frame.
d. At 11:15 a.m., room 9 C 1 door T 9-11 not smoke tight in the frame.
e. At 11:32 a.m., room 8 A 2 door T8-6 not smoke tight in the frame.
f. At 11:40 a.m., room 8 C 3 door T8-17 not smoke tight in the frame.
g. At 12:00 p.m., room 8 B 2 door T8-32 not smoke tight in the frame.
h. At 1:20 p.m., room C 7 3 door T 7-17 not smoke tight in the frame.
i. At 1:25 p.m., room D 17 door T 7-23 not smoke tight in the frame.
j. At 1:45 p.m., room 6 D 1 door T 6-23 not smoke tight in the frame.
k. At 1:50 p.m., room 6 B 3 door T 6-36 not smoke tight in the frame.
l. At 2:15 p.m., room 5 B 3 door T 5-35 not smoke tight in the frame.
m. At 2:20 p.m., room 5 D 3 door T 5-27 not smoke tight in the frame.

2. Observation on January 23, 2020, at 8:10 a.m., revealed the door to room 4 D3, door T 4-25 was not smoke tight latched in the frame.

Exit interview with the facility administrator and the facilities manager on January 23, 2020, between 11:00 a.m. and 11:30 a.m., confirmed the doors lacked smoke tight integrity.



 Plan of Correction - To be completed: 03/20/2020

a. through g.- Doors will be inspected and adjusted accordingly or we will be installing UL rated gap seal product to ensure proper closure of gaps.
Maintenance Supervisor/designee to monitor items are being checked on monthly preventative maintenance. Variances/compliance will be reported to QAPI steering committee.
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: TOWER BUILDING - Component: 03 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain the required fire resistance rating of smoke barrier walls on two of eleven floors.

Findings include:

1. Observation on January 22, 2020, at 1:08 p.m., revealed an open wiring penetration in the smoke barrier behind the nurse station, over the smoke barrier door, on the 7th floor.

Exit interview with the facility administrator and the facilities manager on January 23, 2020, between 11:00 a.m. and 11:30 a.m., confirmed the area around the wires was not sealed.

2. Observation on Jnauary 23, 2020, at 8:12 a.m., revealed the smoke barrier over the smoke barrier door at the staff locker area, was not sealed at the deck.

Exit interview with the facility administrator and the facilities manager on January 23, 2020, between 11:00 a.m. and 11:30 a.m., confirmed the smoke barrier was not closed at the deck.


 Plan of Correction - To be completed: 03/20/2020

1. & 2.- Penetrations will be sealed with 3M CP25WB+ Fire Barrier Sealant.
Will emphasize to crew the importance pf penetration sealing and identifying compromised smoke barriers.

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 Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9
Observations:
Name: TOWER BUILDING - Component: 03 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors on two of eleven floors.

Findings include:

1. Observation on January 22, 2020, between 11:35 a.m. and 1:18 p.m., revealed the following:

a. At 11:35 a.m., the smoke barrier door at the blue shower room, door T8-6, had several holes in the frame from removed hardware.
b. At 1:18 p.m., the smoke barrier door at room 7 A 3, door T-7-7, was not smoke tight while latched in the frame.

Exit interview with the facility administrator and the facilities manager on January 23, 2020, between 11:00 a.m. and 11:30 a.m., confirmed the doors lacked smoke tight integrity.


 Plan of Correction - To be completed: 03/20/2020

a. Steel screws installed on door T8-6.
b. Door will be inspected and adjusted accordingly and UL Rated seal product will be installed to receive proper gap closure.
NFPA 101 STANDARD Gas and Vacuum Piped Systems - Information an:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
Gas and Vacuum Piped Systems - Information and Warning Signs
Piping is labeled by stencil or adhesive markers identifying the gas or vacuum system, including the name of system or chemical symbol, color code (Table 5.1.11), and operating pressure if other than standard. Labels are at intervals not more than 20 feet, are in every room, at both sides of wall penetrations, and on every story traversed by riser. Piping is not painted. Shutoff valves are identified with the name or chemical symbol of the gas or vacuum system, room or area served, and caution to not use the valve except in emergency.
5.1.14.3, 5.1.11.1, 5.1.11.2, 5.2.11, 5.3.13.3, 5.3.11 (NFPA 99)
Observations:
Name: TOWER BUILDING - Component: 03 - Tag: 0909

Based on observation and interview, it was determined the facility failed to identify medical gas piping on one of eleven floors.

Findings include:

1. Observation on January 23, 2020, at 9:05 a.m., revealed oxygen piping above the ceiling outside of the CSR on the 2nd floor lacked labeling.

Exit interview with the facility administrator and the facilities manager on January 23, 2020, between 11:00 a.m. and 11:30 a.m., confirmed the oxygen line was not labeled.





 Plan of Correction - To be completed: 03/20/2020

Pipe was properly labeled at oxygen pipe.

NFPA 101 STANDARD Electrical Systems - Other: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.
Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems 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.
Chapter 6 (NFPA 99)
Observations:
Name: TOWER BUILDING - Component: 03 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems on two of eleven floors.

Findings include:

1. Observation on January 23, 2020, between 8:40 a.m. and 8:55 a.m., revealed the following junction boxes lacked covers.

a. At 8:40 a.m., linen closet on the 3rd floor.
b. At 8:55 a.m., above the ceiling at smoke barrier doors 277 on the 2nd floor.

Exit interview with the facility administrator and the facilities manager on January 23, 2020, between 11:00 a.m. and 11:30 a.m., confirmed the junction boxes were not covered.


 Plan of Correction - To be completed: 03/20/2020

a. & b.- Will install junction box covers to discovered uncovered boxes.
Reminded maintenance staff of the importance of covers even on low voltage boxes.
NFPA 101 STANDARD Electrical Equipment - Other:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
Electrical Equipment - Other
List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, 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.
Chapter 10 (NFPA 99)
Observations:
Name: TOWER BUILDING - Component: 03 - Tag: 0919

Based on observation and interview, it was determined the facility failed to maintain electrical systems in one location, affecting one of eleven floors.

Findings include:

1. Observation on January 23, 2020, at 10:33 a.m., revealed a horizontal penetration of the electrical vault, located at the basement-level.

Exit interview with the facility administrator and the facilities manager on January 23, 2020, between 11:00 a.m. and 11:30 a.m., confirmed the electrical deficiency.



 Plan of Correction - To be completed: 03/20/2020

Penetration will be sealed with 3M CP25WB+ Fire Barrier Sealant.
Maintenance Supervisor/designee will monitor, variances will be reported to the QAPI steering committee.
NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
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: TOWER BUILDING - Component: 03 - Tag: 0923

Based on observation and interview, it was determined the facility failed to secure medical gas cylinders on one of eleven floors.

Findings include:

1. Observation on January 22, 2020, at 1:30 p.m., revealed an unsecured oxygen cylinder in room B4 on the 7th floor.

Exit interview with the facility administrator and the facilities manager on January 23, 2020, between 11:00 a.m. and 11:30 a.m., confirmed the medical gas cylinder was not secured in any way.




 Plan of Correction - To be completed: 03/20/2020

Oxygen Cylinder was secured properly.
Re-education will be provided to Nursing staff regarding the proper storage of oxygen tanks.
Storage will be monitored by nursing staff on routine shift rounds as well as by designated supervisors on monthly environmental rounds of all units.
Results of audits will be reviewed at the monthly QAPI steering meeting.

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