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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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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 on May 13, 2024, 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 May 13-14, 2024, 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 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 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: 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 May 14, 2024, at 8:00 a.m., revealed the facility exceeded the maximum allowable story height for the type of construction.

Interview at exit with the Facility Administrator, Facilities Manager, and Facilities Representative #1 on May 14, 2024, at 10:30 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: 05/31/2024

Request for continuation of FSES

NFPA 101 STANDARD Egress Doors:

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.

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: NORTHWEST WING - Component: 01 - Tag: 0222

Based on observation and interview, the facility failed to maintain egress on one of three floors of this component.

Findings include:

Observation on May 14, 2024, at 9:46 a.m., 1st floor, NW wing, revealed the Bathing Room nearest the linen closet was installed with a deadbolt lock.

Interview at exit with the Facility Administrator, Facilities Manager, and Facilities Representative #1 on May 14, 2024, at 10:30 a.m., confirmed the egress doors deficiency.

Plan of Correction - To be completed: 05/31/2024

Deadbolt permanently removed in bathroom area on NW1. Referenced issue track #152995. Staff will be re-educated on security threat locking a delayed egress. Maintenance designee will report findings to 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: NORTHWEST WING - Component: 01 - Tag: 0321

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

Findings include:

1. Observation on May 14, 2024, at 9:28 a.m., 1st floor, NE wing, revealed the solarium room lacked a self-closing device. (4 file cabinets with records, stored within the room).

Interview at exit with the Facility Administrator, Facilities Manager, and Facilities Representative #1 on May 14, 2024, at 10:30 a.m.,confirmed the hazardous area enclosure deficiencies.

Plan of Correction - To be completed: 05/31/2024

File cabinets shall be permanently removed from the solarium on NE1. Reference Issue Trak #152997. Re-education provided to staff, advised on potential fire hazard areas, maintenance designee will report findings to QAPI Steering Committee.

NFPA 101 STANDARD Corridor - Doors:

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: NORTHWEST WING - Component: 01 - Tag: 0363

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

Findings include:

1. Observation on May 14, 2024, at 9:50 a.m., revealed 1st floor, NW wing, restroom failed to latch into frame when tested, near fire door 32.

Interview at exit with the Facility Administrator, Facilities Manager, and Facilities Representative #1 on May 14, 2024, at 10:30 a.m., confirmed the restroom door failed to latch.

Plan of Correction - To be completed: 05/31/2024

Restroom door shall latch properly and appropriate door stop shall be installed. Reference Issue Trak#152996. Staff Re-educated on properly closing and latching doors. Maintenance designee will report all findings to QAPI Steering Committee.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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 walls in two instances, affecting one of two floors in this component.

Findings include:

1. Observation on May 14, between 8:00 am and 9:00 am, revealed two second floor smoke barrier walls did not extend through the attic to the deck above.

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

Interview at exit with the Facility Administrator, Facilities Manager, and Facilities Representative #1 on May 14, 2024, at 10:30 a.m., confirmed the incomplete smoke barrier walls.

Plan of Correction - To be completed: 05/31/2024

Request for continuation of FSES.

NFPA 101 STANDARD Fire Drills:

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: NORTHWEST WING - Component: 01 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to perform required fire drills under various conditions and times.

Findings include:

1. Review of documentation on May 13, 2024 between 10:30 a.m., and 2:00 p.m., revealed the facility performed the last four third shift fire drills all within the same approximate time frame of the first hour and a half of the shift start.

Interview at exit with the Facility Administrator, Facilities Manager, and Facilities Representative #1 on May 14, 2024, at 10:30 a.m., confirmed the fire drill start times were not varied.

Plan of Correction - To be completed: 05/31/2024

Re-education provided to nursing supervisors regarding random timing of fire drills with a coded announcement being used between 9 pm and 6 am instead of audible alarms.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:

Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)

Observations:
Name: NORTHWEST WING - Component: 01 - Tag: 0761

Based on observation and interview, it was determined the facility failed to ensure that all rated, labeled, doors met the standard of NFPA 80 2010 Edition, affecting two of three floors of this component.

1. Observation on May 14, 2024, between 8:48 a.m., and 9:30 a.m, revealed the following rated door deficiencies:
a. At 8:48 a.m, 2nd floor, NW 2 wing, Fire door frame, Rated label had been painted over, making it so it can not be read.
b. At 9:05 a.m, 2nd floor, SW 2 wing, Fire door frame, Rated label had been painted over, making it so it can not be read.
c. At 9:30 a.m, 1st floor, SW 1 wing, Fire door frame, Rated label had been painted over, making it so it can not be read.

Interview at exit with the Facility Administrator, Facilities Manager, and Facilities Representative #1 on May 14, 2024, at 10:30 a.m., confirmed the fire rated labels had been painted over.

Plan of Correction - To be completed: 05/31/2024

ALL LABELS SHALL BE STRIPPED OF PAINT SO FIRE RATED LABEL IS PROPERLY DISPLAYED. STAFF WILL BE ADVISED ON PROPER FIRE SAFETY AND LABELING. REFERENCE ISSUE TRAK# 152991.
MAINTENANCE DESIGNEE SHALL REPORT FINDINGS TO QAPI STEERING COMMITTEE.

Initial comments:Name: MAIN BUILDING - Component: 02 - Tag: 0000

Facility ID# 072802
Component 02
Main Building

Based on a Medicare/Medicaid Recertification Survey completed May 13-14, 2024, 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, a basement-level crawl space, penthouse, and an unused attic, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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 sprinkler system on one of three floors.

Findings include:

1. Observation on May 14, 2024, at 8:53 a.m., revealed a sprinkler in the nurse station closet SE-2, 2nd floor, was missing an escutcheon.

Interview at exit with the Facility Administrator, Facilities Manager, and Facilities Representative #1 on May 14, 2024, at 10:30 a.m., confirmed the trim piece was missing.

Plan of Correction - To be completed: 05/31/2024

SE-2 SPRINKLER ESCUTCHEON REINSTALLED. REFERENCE ISSUE TRAK # 153000. STAFF RE EDUCATED IN IDENITFYING UNSEALED PENETRATIONS.

NFPA 101 STANDARD Fire Drills:

Observations:
Name: MAIN BUILDING - Component: 02 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to perform required fire drills under various conditions and times.

Findings include:

1. Review of documentation on May 13, 2024, between 10:30 a.m., and 2:00 p.m., revealed the facility performed the last four third shift fire drills all within the same approximate time frame of the first hour and a half of the shift start.

Interview at exit with the Facility Administrator, Facilities Manager, and Facilities Representative #1 on May 14, 2024, at 10:30 a.m., confirmed the fire drill start times were not varied.

NFPA 101 STANDARD Gas and Vacuum Piped Systems - Other:

Gas and Vacuum Piped Systems - Other
List in the REMARKS section any NFPA 99 Chapter 5 Gas and Vacuum 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 5 (NFPA 99)

Observations:
Name: MAIN BUILDING - Component: 02 - Tag: 0902

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

Findings include;

1. Observation on May 14, 2024, at 9:00 a.m., revealed steel cabling in direct contact with the medical gas copper pipes above the ceiling near room SE-2-8 on the 2nd floor.

Interview at exit with the Facility Administrator, Facilities Manager, and Facilities Representative #1 on May 14, 2024, at 10:30 a.m., confirmed the metallic cables were in contact with the medical gas piping.

Plan of Correction - To be completed: 05/31/2024

SE-2 CABELING SHALL BE SECURED AND SEPERATED FROM ALL OXYGEN LINES. REFERENCE ISSUE TRAK #153001. STAFF RE-EDUCATED ON GAS AND VACUUMED PIPE SYSTEMS.

NFPA 101 STANDARD Electrical Systems - Other:

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: MAIN BUILDING - Component: 02 - Tag: 0911

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

Findings include:

1. Observation on May 14, 2024, at 10:09 a.m., revealed an open junction box on the ceiling in the basement level central storage area, SW wing.

Interview at exit with the Facility Administrator, Facilities Manager, and Facilities Representative #1 on May 14, 2024, at 10:30 a.m., confirmed the junction box lacked a cover.

Plan of Correction - To be completed: 05/31/2024

SW BASEMENT STOREROOM JUNCTION BOX. WIRES SHALL BE FITTED AND SEALED INSIDE JUNCTION BOX. REFERENCE ISSSUE TRAK #152994. STAFF RE EDUCATED IN ELECTRICAL SYSTEM REQUIREMENTS. MAINTENACE DESIGNEE SHALL REPORT ALL FINDINGS TO QAPI STEERING COMMITTEE.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

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 - Component: 02 - Tag: 0923

Based on observation and interview, it was determined the facility failed to provide for the storage of portable medical gas on one of three floors.

Findings include:

1. Observation on May 14, 2024, at 8:40 a.m., revealed several protable oxygen cylinders being stored without signage or a tag to indicate if the cylinder was ready for use or empty. When a staff person in the area was questioned about how to determine if a cylinder was full or empty they could not provide an answer.

Interview at exit with the Facility Administrator, Facilities Manager, and Facilities Representative #1 on May 14, 2024, at 10:30 a.m., confirmed there was no tag or signage to determine if the cylinders in the carts were full or empty.

Plan of Correction - To be completed: 06/15/2024

Oxygen cylinder status hang tags have been ordered and will be applied to new oxygen cylinders on delivery. Re-education will be provided to appropriate staff, including nursing and housekeeping, in hang tag use.

Supervisors will monitor on routine rounds. Housekeeping staff will audit stored tanks and 10 in-use tanks weekly for 6 weeks with results reported to QAPI Steering Committee.

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

Facility ID# 072802
Component 03
Building 03
Tower Building

Based on a Medicare/Medicaid Recertification Survey completed May 13-14, 2024, 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 ten story, Type II (222), fire resistive building, with miscellaneous rooftop mechanical spaces, and a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Exit Signage:

Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Observations:
Name: TOWER BUILDING - Component: 03 - Tag: 0293

Based on observation and interview, the facility failed to ensure that access to exits were marked by readily visible signs in one area, on one of eleven floors of this component.

Findings include:

Observation on May 13, 2024, at 1:05 p.m., Floor 6, D-hall near the nurses station, revealed the facility lacked directional exit signs directing egress travel. Exit sign was provided but turned so that the directional arrow did not point to exit access.

Interview at exit with the Facility Administrator, Facilities Manager, and Facilities Representative #1 on May 14, 2024, at 10:30 a.m., confirmed the exit sign was not pointed in the direction of exit access.

Plan of Correction - To be completed: 05/31/2024

EXIT SIGN SHALL BE PLACED IN ACCORDANCE WITH LIFE SAFETY CODE. REFERENCE ISSUE TRAK #152992. STAFF SHALL BE RE- EDUCATED IN PROPER FIRE SAFETY DISPLAYS AND SIGNAGE. MAINTENACE DESIGNEE SHALL REPORT ALL FINDINGS TO QAPI Steering Committee.

NFPA 101 STANDARD Portable Fire Extinguishers:

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 accessible access to fire extinguisher in two locations, affecting two of eleven floors.

Findings include:

1. Observation on May 13, 2024, between 1:03 p.m., and 1:19 p.m., revealed the following:

a. At 1:03 p.m., 6th floor, C-Hall, fire extinguisher was blocked by wheelchairs.
b. At 1:16 p.m., 5th floor B-Hall, fire extinguisher was blocked by a lift.
c. At 1:19 p.m., 5th floor C-Hall, fire extinguisher was blocked by wheelchairs.

Interview at exit with the Facility Administrator, Facilities Manager, and Facilities Representative #1 on May 14, 2024, at 10:30 a.m., confirmed the fire extinguishers were blocked.

Plan of Correction - To be completed: 06/15/2024

Re-education regarding unimpeded access to fire extinguishers provided to all staff. Tape will be applied to floor to provide visual cue to staff regarding area to be kept clear. Environmental Services staff will monitor routinely.

Nursing Supervisors to monitor compliance on routine rounds. Environmental Services Supervisors will complete 10 random audits weekly for 6 weeks with results reported to QAPI Steering Committee.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Observations:
Name: TOWER BUILDING - Component: 03 - Tag: 0372

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

Findings include:

1. Observation on May 13, 2024, between 11:10 a.m., and 1:12 p.m., revealed the following unsealed smoke barrier penetrations:

a. At 11:10 a.m., 10th floor, unsealed penetration in wall above fire/smoke barrier doors 315/316, near elevator #8.
b. At 1:12 p.m., 5th floor, unsealed penetration in wall above fire/smoke barrier doors 290/291, near elevator #8.

Interview at exit with the Facility Administrator, Facilities Manager, and Facilities Representative #1 on May 14, 2024, at 10:30 a.m., confirmed the penetrations in the smoke wall.

Plan of Correction - To be completed: 05/31/2024

PENETRATIONS ON FIRE WALL IN THE TOWER ON THE 10TH AND 5TH FLOOR SHALL BE PROPERLY SEALED. REFERENCE ISSUE TRAK #152993. STAFF RE-EDUCATED IN UNSEALED PENETRATIONS.

NFPA 101 STANDARD Fire Drills:

Observations:
Name: TOWER BUILDING - Component: 03 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to perform required fire drills under various conditions and times.

Findings include:

1. Review of documentation on May 13, 2024, between 10:30 a.m., and 2:00 p.m., revealed the facility performed the last four third shift fire drills all within the same approximate time frame of the first hour and a half of the shift start.

Interview at exit with the Facility Administrator, Facilities Manager, and Facilities Representative #1 on May 14, 2024, at 10:30 a.m., confirmed the fire drill start times were not varied.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:

Observations:
Name: TOWER BUILDING - Component: 03 - Tag: 0761

Based on observation and interview, it was determined the facility failed to ensure that all rated, labeled doors met the standard of NFPA 80 2010 Edition, affecting three of eleven floors of this component.

1. Observation on May 13, 2024, between 11:28 a.m., and 12:30 p.m, revealed the following rated door deficiencies:

a. At 11:28 a.m, 10th floor, fire door frame, rated label had been painted over, making it so it can not be read.
b. At 11:45 a.m, 9th floor, fire door frame, rated label had been painted over, making it so it can not be read.
c. At 12:30 p.m, 6th floor, fire door frame, rated label had been painted over, making it so it can not be read.

Interview at exit with the Facility Administrator, Facilities Manager, and Facilities Representative #1 on May 14, 2024, at 10:30 a.m., confirmed the fire rated labels, had been painted over.

Plan of Correction - To be completed: 05/31/2024

ALL LABELS SHALL BE STRIPPED OF PAINT SO FIRE RATED LABEL PROPERLY DISPLAYED. STAFF WILL BE ADVISED ON PROPER FIRE SAFETY AND LABELING. REFERENCE ISSUE TRAK# 152991.
MAINTENANCE DESIGNEE SHALL REPORT FINDINGS TO QAPI Steering Committee.

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