Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on May 1, 2023, at Martha Lloyd Creekside, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.475.
Plan of Correction:
Initial Comments:
Name - NEW ICF/IID Component - 01
Facility ID #24901101
Component 01
Main Building 01
Based on a Medicaid Recertification Survey completed on May 1, 2023, it was determined that Martha Lloyd Creekside, was not in compliance with the following requirements of the Life Safety Code for an existing ICF/IID health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.470(j).
This is a one story, Type V (000), unprotected, wood-frame building, that is fully sprinklered.
State plans approved as Impractical.
Plan of Correction:
NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing
Name - NEW ICF/IID Component - 01
Sprinkler System - Maintenance and Testing
2012 NEW
NFPA 13 and 13R Systems
All sprinkler systems installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, and NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies Up To and Including Four Stories in Height, are inspected, tested and maintained in accordance with NFPA 25, Standard for Inspection, Testing and Maintenance of Water Based Fire Protection System.
NFPA 13D Systems
Sprinkler systems installed in accordance with NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes, are inspected, tested and maintained in accordance with the following requirements of NFPA 25:
1. Control valves inspected monthly (NFPA 25, section 13.3.2).
2. Gauges inspected monthly (NFPA 25, section 13.2.71).
3. Alarm devices inspected quarterly (NFPA 25, section 5.2.6).
4. Alarm devices tested semiannually (NFPA 25, section 5.3.3).
5. Valve supervisory switches tested semiannually (NFPA 25, section 13.3.3.5).
6. Visible sprinklers inspected annually ((NFPA 25, section 5.2.1).
7. Visible pipe inspected annually (NFPA 25, section 5.2.2).
8. Visible pipe hangers inspected annually (NFPA 25, section 5.2.3).
9. Buildings inspected annually prior to freezing weather for adequate heat for water filled piping (NFPA 25, section 5.2.5).
10. A representative sample of fast response sprinklers are tested at 20 years (NFPA 25, section 5.3.1.1.1.2).
11. A representative sample of dry pendant sprinklers are tested at 10 years (NFPA 25, section 5.3.1.1.15).
12. Antifreeze solutions are tested annually (NFPA 25, section 5.3.4).
13. Control valves are operated through their full range and returned to normal annually (NFPA 25, section 13.3.3.1).
14. Operating stems of OS&Y valves are lubricated annually (NFPA 25, section 13.3.4).
15. Dry pipe systems extending into unheated portions of the building are inspected, tested and maintained (NFPA 25, section 13.4.4).
A. Date sprinkler system last checked and necessary maintenance provided. __________________________
B. Show who provided the service. _________________________
C. Note the source of the water supply for the automatic sprinkler system.__________________________________
32.2.3.5.3, 9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Based on observation and interview, it was determined the facility failed to maintain sprinkler systems, affecting two of two smoke compartments.
Findings include:
1. Observation on May 1, 2023, at 9:35 a.m., revealed the lack of a required sprinkler head wrench.
Exit interview with facility representative #1, on May 1, 2023, at 9:36 a.m., confirmed the lack of a wrench.
Plan of Correction:Regarding item 1, the facility Maintenance Supervisor has requested a replacement sprinkler head wrench was from Susquehanna Sprinkler. In the meantime, an additional sprinkler head wrench was ordered and is scheduled to be delivered between May 12, 2023- May 15th, 2023. In addition to replacing the sprinkler head wrench, the maintenance department will include checking for this on their quarterly safety checklist provided by Susquehanna Sprinkler. The Maintenance Supervisor will assure that the safety checklists are completed quarterly and include the sprinkler head wrench and will have overall responsibility for the effective of these interventions.
NFPA 101 STANDARD
Utilities - Gas and Electric
Name - NEW ICF/IID Component - 01
Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NPFA 70, National Electric Code.
32.2.5.1, 33.2.5.1, 9.1.1, 9.1.2
Observations:
Based on observation and interview, it was determined the facility failed to maintain electrical wiring and equipment, affecting one of two smoke compartments.
Findings include:
1. Observation on May 1, 2023, at 9:30 a.m., revealed the bed located in client room #1, was placed against an electrical receptacle.
Exit interview with facility representative #1, on May 1, 2023, at 9:31 a.m., confirmed the bed placed against an electrical receptacle.
Plan of Correction:On 5/1/23, a bed was found to be placed against the wall near an electrical receptable. The bed was immediately moved away from the wall at this time. During a facility team meeting on May 9, 2023, all ICF staff were retrained on the importance of keeping beds away from walls that have electrical receptacles. In addition to this, house managers will ensure that no beds are placed against electrical receptacles during their monthly safety inspections. These checks will be noted on their monthly safety checklist. The ICF/ID Supervisor will have overall responsibility for the effectiveness of these interventions.
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