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Tag No.: K0324
Based on a review of documentation and an interview with staff, it was determined that the kitchen hood suppression system is not in accordance with NFPA 101 The Life Safety Code (edition 2012), Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2
Findings Include:
On 05/17/2017 at 9 am, review of the documents titled "Tyco Range Hood Suppression System Inspection" dated 12/30/16 revealed a statement that read "Hydro testing of cylinder recommended." The facility was unable to provide evidence of the hydro testing having been accomplished and a later review of the range hood suppression system that same day, revealed a tag on the cylinder that indicated hydro testing was recommended.
This deficient practice was confirmed by the facility Maintenance staff at the time of discovery and at the exit conference.
Tag No.: K0341
Based on observations and staff interview the facility failed to install the smoke detection in accordance with NFPA 101 Life Safety Code (2012) section 19.3.4.1, 9.6.1.3 and NFPA 72 National Fire Alarm Code (2010) section 17.7.4.1. This deficient practice could affect the ability of the alarm system to sound in a timely manner during a fire event which could affect 4 of the 24 residents and an undetermined amount of staff and visitors.
Findings include:
On 05/17/2017 between 9:00 AM and 2:00 PM during the facility tour, observations and staff interview revealed a smoke detector with 36 inches of an HVAC diffuser in the following areas:
1) 2nd floor administration
2) By room 17
3) By room 22
4) Transcription
5) Housekeeping storage lower level
This deficient practice was confirmed by the facility Maintenance staff at the time of discovery and at the exit conference.
Tag No.: K0345
Based on documentation review and interview, the Facility failed to test and maintain the Fire Alarm System in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. The deficient practice could affect and undetermined amount of patients, visitors and staff.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.7.5, 9.7.7, 9.7.8, and NFPA 25.
Findings include:
On 05/17/2017 at 9 AM, documentation reviewed revealed that the FIRE ALARM was not tested annually and the DACT System was not tested monthly during the following times:
1) 1st quarter 2nd shift of 2017
2) 2nd quarter 1st and 3rd shift of 2016
3) 3rd quarter 2nd shift of 2016
4) 4th quarter 1st and 3rd shift of 2016
Fire alarm was last tested on 05/02/2016, during interview the annual maintenance was not scheduled at the time of the survey.
This deficient practice was confirmed by the facility Maintenance staff at the time of discovery and at the exit conference.
Tag No.: K0353
Based on observation and interview, the facility failed to ensure that the sprinklers were maintained. This had a potential to affect approximately 4 of the 4 patients in the 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
Findings Include:
On 05/17/2017 at 9 AM, based on review of available documentation and interview the Fire Sprinkler System was last tested on 05/02/2016. The annual maintenance was not scheduled at the time of the survey.
On 05/17/2017 between 9:00 AM and 2:00 PM during the facility tour, observations and staff interview revealed missing ceiling tiles in the following areas:
1) The clean utility/storage room by rm 13
2) The vending area has a ceiling tile with a hole in it because the speaker was not brought back down after repair.
This deficient practice was confirmed by the facility Maintenance staff at the time of discovery and at the exit conference.
Tag No.: K0712
Based on record review and staff interview the facility failed to provide documentation of fire drills at least quarterly on each shift as required by the Life Safety Code (NFPA 101) 2012 edition, section 19.7.1.4 to 19.7.1.7. This deficient practice could reduce the ability of staff to conduct a safe and timely response to a fire emergency, which would affect all residents and an undetermined amount of staff and visitors.
Findings include:
On 05/17/2017 at 9 AM, documentation reviewed revealed Fire drills were not performed during these times:
1) 1st quarter 2nd shift of 2017
2) 2nd quarter 1st and 3rd shift of 2016
3) 3rd quarter 2nd shift of 2016
4) 4th quarter 1st and 3rd shift of 2016
This deficient practice was confirmed by the facility Maintenance staff at the time of discovery and at the exit conference.
Tag No.: K0781
Based on documentation review and interview, the Facility failed to provide a written and current Space Heater Policy. This deficient practice could affect and undetermined amount of patients.
Portable Space Heaters
Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius).
18.7.8, 19.7.8
Findings include:
On 05/17/2017 at 9 AM, documentation reviewed revealed that the facility does not have a written Space Heater Policy that is specific to Centracare Health System - Sauk Centre Critical Access Hospital.
This deficient practice was confirmed by the facility Maintenance staff at the time of discovery and at the exit conference.
Tag No.: K0923
Based on observation and staff interview the facility failed to store oxygen tanks in accordance with NFPA 99 (Health Care Facilities Code) 2012 edition section 11.6.2.3 item 11. This deficient practice could create an oxygen filled atmosphere and accelerate the spread of fire. This condition could affect all of the 4 patients and an undetermined amount of staff and visitors.
Findings include:
On 05/17/2017 between 9:00 AM and 2:00 PM during the facility tour, observations and staff interview revealed 33 "E Cylinders", 4 not restrained approximately 40 "H Cylinders" that were not secured in a room approximately 84 sq feet.
This deficient practice was confirmed by the facility Maintenance staff at the time of discovery and at the exit conference.