Pennsylvania Department of Health
RIVERTON REHABILITATION AND HEALTHCARE CENTER
Building Inspection Results

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RIVERTON REHABILITATION AND HEALTHCARE CENTER
Inspection Results For:

There are  43 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
RIVERTON REHABILITATION AND HEALTHCARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on January 25, 2024, at Riverton Rehabilitation and Healthcare Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.




 Plan of Correction:


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


Facility ID# 124102
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 25, 2024, it was determined that Riverton Rehabilitation and Healthcare Center was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a three story, Type II (222), fire resistive building, with unused attic spaces, that is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD General Requirements - 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.
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0100

28 Pa. Code 201.14(a). RESPONSIBILITY OF THE LICENSEE

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met.

35 P.S. 448.808. Issuance of license.

(a)STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered.

Based on observation and interview, it was determined the following item(s) did not meet the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents within the facility.

Findings include:

Observation on January 25, 2024, at 11:55 a.m., revealed the facility had replaced the existing generator set with a portable, temporary generator, and had failed to contact the Division of Safety Inspection.

Exit interview on January 25, 2024, between 12:00 p.m., and 12:15 p.m., with the Facilities Manager and the Facility Administrator, confirmed the above deficiency.








 Plan of Correction - To be completed: 03/05/2024

1. The Administrator has notified the Division of Safety Inspection of the temporary generator.

2. The Maintenance Director/Designee will conduct an initial audit to verify if any other facility changes need to be reported to the Division of Safety Inspection.

3. Regional Director of Operations will educate Administrator and Maintenance Director on required reportable incidents.

4. The Maintenance Director/Designee will conduct weekly audits for four weeks and then monthly for two months thereafter to verify if any other facility changes need to be reported to the Division of Safety Inspection. This plan of correction will be reviewed at the monthly Quality Assurance Performance Improvement meeting and changes will be made as needed.
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 01 - Component: 01 - Tag: 0161

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

Findings include:

1. Observation on January 25, 2024, at 11:33 a.m., revealed a section of the monolithic portion of the rated ceiling assembly, located within the first floor, Main Mechanical Room, was damaged, due to a water leak.

Exit interview on January 25, 2024, between 12:00 p.m., and 12:15 p.m., with the Facilities Manager and the Facility Administrator, confirmed the building construction deficiency.




 Plan of Correction - To be completed: 03/05/2024

1. The Maintenance Director corrected water damaged ceiling in first floor mechanical room.

2. The Maintenance Director/Designee will conduct an initial audit to verify that ceiling is dry in first floor mechanical rooms.

3. Nursing Home Administrator or Designee will re-educate the maintenance director on properly identifying damaged ceiling tiles.

4. The Maintenance Director/Designee will conduct weekly audits for four weeks and then monthly for two months thereafter to verify that ceiling is dry in first floor mechanical rooms. This plan of correction will be reviewed at the monthly Quality Assurance Performance Improvement meeting and changes will be made as needed.
NFPA 101 STANDARD Corridor - Doors:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363

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

Findings include:

1. Observation on January 25, 2024, at 10:22 a.m., revealed the third floor, Resident Room 301 door was not smoke-tight.

Exit interview on January 25, 2024, between 12:00 p.m., and 12:15 p.m., with the Facilities Manager and the Facility Administrator, confirmed the corridor opening deficiency.



 Plan of Correction - To be completed: 03/05/2024

1. The Maintenance Director corrected resident room 301 door, ensuring it is smoke tight.

2. The Maintenance Director/Designee will conduct an initial audit to verify resident rooms on third floor are smoke tight.

3. Nursing Home Administrator or Designee will re-educate the maintenance director on properly identifying smoke tight doors.

4. The Maintenance Director/Designee will conduct weekly audits for four weeks and then monthly for two months thereafter to verify that resident rooms on third floor are smoke tight. This plan of correction will be reviewed at the monthly Quality Assurance Performance Improvement meeting and changes will be made as needed.
NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372

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

Findings include:

1. Observation on January 25, 2024, at 11:17 a.m., revealed non-rated, foam insulating materials, located within the second floor, smoke barrier separation wall, located closest to Clean Utility.

Exit interview on January 25, 2024, between 12:00 p.m., and 12:15 p.m., with the Facilities Manager and the Facility Administrator, confirmed the smoke barrier separation wall deficiency.




 Plan of Correction - To be completed: 03/05/2024

1. The Maintenance Director corrected non-rated, foam insulating materials in 2nd floor clean utility closet and replaced with seal using an UL approved through penetration fire stop system.

2. The Maintenance Director/Designee will conduct an initial audit to verify 2nd floor utility closets are not utilizing any non rated, foam insulating materials.

3. Nursing Home Administrator or Designee will re-educate the Maintenance Director on proper foam insulating materials.

4. The Maintenance Director/Designee will conduct weekly audits for four weeks and then monthly for two months thereafter to verify 2nd floor utility closets are not utilizing any non rated, foam insulating materials. This plan of correction will be reviewed at the monthly Quality Assurance Performance Improvement meeting and changes will be made as needed.
NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0541

Based on observation and interview, it was determined the facility failed to maintain one soiled linen chute in two locations, affecting two of three floors.

Findings include:

1. Observation on January 25, 2024, between 10:50 a.m., and 11:11 a.m., revealed the following soiled linen chute room access panels lacked positive latching:

a. 10:50 a.m., third floor.
b. 11:11 a.m., second floor.

Exit interview on January 25, 2024, between 12:00 p.m., and 12:15 p.m., with the Facilities Manager and the Facility Administrator, confirmed the soiled linen chute deficiencies.




 Plan of Correction - To be completed: 03/05/2024

1. The Maintenance Director corrected 2nd and 3rd floor soiled linen chutes to have positive latching.

2. The Maintenance Director/Designee will conduct an initial audit to verify facility soiled linen chutes have positive latching.

3. Administrator/Designee will re-educate the Maintenance Director on properly identifying positive latching doors.

4. The Maintenance Director/Designee will conduct weekly audits for four weeks and then monthly for two months thereafter to verify facility soiled linen chutes have positive latching. This plan of correction will be reviewed at the monthly Quality Assurance Performance Improvement meeting and changes will be made as needed.
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Electrical Systems - Essential Electric System Alarm Annunciator
A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator.
6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0916

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

Findings include:

1. Observation on January 25, 2024, at 11:40 a.m., revealed the remote annunciator was not functional.

Exit interview on January 25, 2024, between 12:00 p.m., and 12:15 p.m., with the Facilities Manager and the Facility Administrator, confirmed the essential electrical system deficiency.





 Plan of Correction - To be completed: 03/05/2024

1. The Maintenance Director corrected facility annunciator, connecting it to the generator.

2. The Maintenance Director/Designee will conduct an initial audit to verify facility annunciator is functioning.

3. Administrator/Designee will re-educate the Maintenance Director on properly identifying that annunciator is properly functioning.

4. The Maintenance Director/Designee will conduct weekly audits for four weeks and then monthly for two months thereafter to verify facility annunciator is functioning. This plan of correction will be reviewed at the monthly Quality Assurance Performance Improvement meeting and changes will be made as needed.
Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000


Facility ID# 124102
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 25, 2024, it was determined that Riverton Rehabilitation and Healthcare Center 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 one story, Type II (000), unprotected, noncombustible building, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Building Rehabilitation: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 Rehabilitation
Repair, Renovation, Modification, or Reconstruction
Any building undergoing repair, renovation, modification, or reconstruction complies with both of the following:
* Requirements of Chapter 18 and 19
* Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6
18.1.1.4.3, 19.1.1.4.3, 43.1.2.1
Change of Use or Change of Occupancy
Any building undergoing change of use or change of occupancy classification complies with the requirements of Section 43.7, unless permitted by 18.1.1.4.2 or 19.1.1.4.2
18.1.1.4.2 (4.6.7 and 4.6.11), 19.1.1.4.2 (4.6.7 and 4.6.11), 43.1.2.2 (43.7)
Additions
Any building undergoing an addition shall comply with the requirements of Section 43.8. If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a 2-hour fire resistance rating constructed of materials as required for the addition.
Communicating openings occur only in corridors and are protected by approved self-closing fire doors with at least a 1-1/2-hour fire resistance rating. Additions comply with the requirements of Section 43.8.
18.1.1.4.1 (4.6.7 and 4.6.11), 18.1.1.4.1.1 (8.3), 18.1.1.4.1.2, 18.1.1.4.1.3, 19.1.1.4.1 (4.6.7 and 4.6.11), 19.1.1.4.1.1 (8.3), 19.1.1.4.1.2, 19.1.1.4.1.3, 43.1.2.3(43.8)
Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0111

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

Findings include:

1. Observation on January 25, 2024, at 11:44 a.m., revealed the exit discharge door, located closest to the Staff Lounge, had recently been changed to "delayed egress," without notifying the Division of Safety Inspection/Plan Review.

Exit interview on January 25, 2024, between 12:00 p.m., and 12:15 p.m., with the Facilities Mnager and the Facility Administrator, confirmed the building rehabilitation requirments deficiency.




 Plan of Correction - To be completed: 03/05/2024

1. Administrator reported "delayed egress," of staff lounge door to Division of Safety Inspection/Plan Review.

2. The Maintenance Director/Designee will conduct an initial audit to verify if any other facility changes need to be reported to the Division of Safety Inspection/Plan Review.

3. Regional Director of Operations will educate Administrator and Maintenance Director on required reportable incidents.

4. The Maintenance Director/Designee will conduct weekly audits for four weeks and then monthly for two months thereafter to verify if any other facility changes need to be reported to the Division of Safety Inspection. This plan of correction will be reviewed at the monthly Quality Assurance Performance Improvement meeting and changes will be made as needed.
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: BUILDING 02 - Component: 02 - 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 25, 2024, at 11:41 a.m., revealed discarded cigarettes were located within the trash receptacle at the outdoor smoking location.

Exit interview on January 25, 2024, between 12:00 p.m., and 12:15 p.m., with the Facilities Manager and the Facility Administrator, confirmed the smoking regulations deficiency.



 Plan of Correction - To be completed: 03/05/2024

1. The Maintenance Director corrected the discarded cigarettes located within the trash receptacle at the outdoor smoking location.

2. The Maintenance Director/Designee will conduct an initial audit to verify cigarette butts on the campus are disposed of properly.

3. Administrator/Designee will re-educate the Maintenance Director on cigarette butt disposal. Administrator will educate employees who smoke on smoking location and proper smoking waste disposal.

4. The Maintenance Director/Designee will conduct weekly audits for four weeks and then monthly for two months thereafter to verify cigarette butts on the campus are disposed of properly. This plan of correction will be reviewed at the monthly Quality Assurance Performance Improvement meeting and changes will be made as needed.
Initial comments:Name: BUILDING 03 - Component: 03 - Tag: 0000


Facility ID# 124102
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 25, 2024, it was determined that Riverton Rehabilitation and Healthcare Center was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a three story, Type II (111), protected, noncombustible building, that is fully sprinklered.



 Plan of Correction:


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: BUILDING 03 - Component: 03 - Tag: 0363

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

Findings include:

1. Observation on January 25, 2024, at 10:07 a.m., revealed the third floor, RNAC Office door was not smoke-tight.

Exit interview on January 25, 2024, between 12:00 p.m., and 12:15 p.m., with the Facilities Manager and the Facility Administrator, confirmed the corridor opening deficiency.



 Plan of Correction - To be completed: 03/05/2024

1. The Maintenance Director corrected RNAC office door, ensuring it is smoke tight.

2. The Maintenance Director/Designee will conduct an initial audit to verify offices on third floor are smoke tight.

3. Nursing Home Administrator or Designee will re-educate the maintenance director on properly identifying smoke tight doors.

4. The Maintenance Director/Designee will conduct weekly audits for four weeks and then monthly for two months thereafter to verify that offices on third floor are smoke tight. This plan of correction will be reviewed at the monthly Quality Assurance Performance Improvement meeting and changes will be made as needed.
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: BUILDING 03 - Component: 03 - Tag: 0923

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

Findings include:

1. Observation on January 25, 2024, at 10:02 a.m., revealed one of four, third floor, oxygen storage room walls was not complete to the roof deck above.

Exit interview on January 25, 2024, between 12:00 p.m., and 12:15 p.m., with the Facilities Manager and the Facility Administrator, confirmed the oxygen storage room deficiency.






 Plan of Correction - To be completed: 03/05/2024

1. The Maintenance Director corrected wall in oxygen storage so it is now complete to roof deck above.

2. The Maintenance Director/Designee will conduct an initial audit to verify storage spaces on third floor have walls to the roof deck above.

3. Nursing Home Administrator or Designee will re-educate the maintenance director on properly identifying walls complete to the roof deck above.

4. The Maintenance Director/Designee will conduct weekly audits for four weeks and then monthly for two months thereafter to verify storage spaces on third floor have walls to the roof deck above. This plan of correction will be reviewed at the monthly Quality Assurance Performance Improvement meeting and changes will be made as needed.

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