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Based on record review and interview, it was determined the facility failed to ensure the fire alarm system was maintained in accordance with National Fire Protection Association (NFPA) standards. The deficiency had the potential to affect all smoke compartments, residents, staff and visitors. The facility has the capacity for twenty- five (25) beds and at the time of the survey the census was eleven (11).

The findings include:

Record review on 03/03/2020 at 9:26 AM with the Maintenance Director revealed a smoke detector sensitivity test had not been performed in the last two years.

Interview on 03/03/2020 at 9:27 AM with the Maintenance Director revealed he was not aware a smoke detector sensitivity test had not been performed in the last two years. Further interview revealed the Maintenance Director was aware of the requirements for maintaining smoke detectors in the facility.

The census of eleven (11) was verified by the Director on 03/03/2020. The findings were acknowledged by the Administrator and verified by the Maintenance Director at the exit interview on 03/03/2020.


Reference: NFPA 101 (2012 Edition) Life Safety Code

9.6 Fire Detection, Alarm, and Communications Systems.
9.6.1* General.
9.6.1.1 The provisions of Section 9.6 shall apply only where specifically required by another section of this Code.
9.6.1.2 Fire detection, alarm, and communications systems installed to make use of an alternative permitted by this Code shall be considered required systems and shall meet the provisions of this Code applicable to required systems.
9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

Based on record review and interview, it was determined the facility failed to ensure the sprinkler system was maintained in accordance with National Fire Protection Association (NFPA) standards. The deficiency had the potential to affect all smoke compartments, residents, staff and visitors. The facility has the capacity for twenty-five (25) beds and at the time of the survey the census was eleven (11).

The findings include:

Record review on 03/03/2020 at 9:43 AM with the Maintenance Director revealed an internal pipe inspection had not been performed in the last five (5) years.

Interview on 03/03/2020 at 9:44 AM with the Maintenance Director revealed he was not aware that an internal pipe inspection had not been performed in the last five (5) years. Further interview revealed the Maintenance Director was aware of the requirements for maintaining the sprinkler system in the facility.

The census of eleven (11) was verified by the Director on 03/03/2020. The findings were acknowledged by the Administrator and verified by the Maintenance Director at the exit interview on 03/03/2020.



Reference: NFPA 101 (2012 Edition) Life Safety Code

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected,
tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.

Based on observation and interview, it was determined the facility failed to ensure smoke barriers were maintained in accordance with National Fire Protection Association (NFPA) standards. The deficiency had the potential to affect one (1) of four (4) smoke compartments, residents, staff and visitors. The facility has the capacity for twenty-five (25) beds and at the time of the survey the census was eleven (11).

The findings include:

Observation on 03/03/2020 at 1:17 PM with the Maintenance Director revealed a penetration in the smoke wall in the MRI Equipment Room. Further observation revealed a hole had been cut in the smoke wall to accommodate the wiring for the MRI. The hole was not sealed properly and therefore would not resist the passage of smoke.

Interview on 03/03/2020 at 1:18 PM with the Maintenance Director revealed he was not aware of the smoke wall penetration in the MRI Equipment Room. Further interview revealed the Maintenance Director was aware of the requirements for maintaining smoke barriers.


The census of eleven (11) was verified by the Director on 03/03/2020. The findings were acknowledged by the Administrator and verified by the Maintenance Director at the exit interview on 03/03/2020.




Reference: NFPA 101 (2012 Edition)

Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
19.3.7.3, 8.6.7.1

Smoke barriers shall be constructed to a ½ 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.

Based on observation and interview, it was determined the facility failed to ensure electrical wiring was installed and maintained in accordance with National Fire Protection Association (NFPA) standards. The deficiency had the potential to affect one (1) of five (5) smoke compartments, residents, staff and visitors. The facility has the capacity for twenty-five (25) beds and at the time of the survey the census was eleven (11).

The findings include:

Observation on 003/03/2020 at 1:15 PM with the Maintenance Director revealed a power strip plugged in to an extension cord in the MRI Equipment Room.

Interview on 03/03/2020 at 1:16 PM with the Maintenance Director revealed he was not aware there was a power strip plugged in to an extension cord in the MRI Equipment Room. Further interview revealed the Maintenance Director was aware of the requirements for electric wiring in the facility.


The census of eleven (11) was verified by the Director on 003/03/2020 . The findings were acknowledged by the Director and verified by the Maintenance Director at the exit interview on 03/03/2020.


NFPA 101 Life Safety Code (2012 Edition)
10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5


Electrical Equipment - Power Cords and Extension Cords

Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Based on observation and interview, it was determined the facility failed to ensure oxygen cylinders were stored in accordance with National Fire Protection Association (NFPA) standards. The deficiency had the potential to affect two (2) of five (5) smoke compartments, residents, staff and visitors. The facility has the capacity for twenty-five (25) beds and at the time of the survey the census was eleven (11).

The findings include:

1. Observation on 03/03/2020 at 1:13 PM with the Maintenance Director revealed twelve (12) oxygen cylinders in the oxygen storage closet on 100 Hall were being stored within five (5) feet of combustibles.

Interview on 03/03/2020 at 1:14 PM with the Maintenance Director revealed he was not aware that the oxygen cylinders in the oxygen storage closet on 100 Hall were being stored within five (5) feet of combustibles. Further interview revealed the Maintenance Director was aware of the requirements of maintaining the facility's oxygen storage areas.

The census of eleven (11) was verified by the Director on 03/03/2020. The findings were acknowledged by the Director and verified by the Maintenance Director at the exit interview on 03/03/2020.

2. Observation on 03/03/2020 at 1:40 PM with the Maintenance Director revealed there were oxygen cylinders being stored in the MRI Equipment Room. Further observation revealed the MRI Equipment Room did not have a sign on the door indicating oxygen storage and the MRI Equipment Room Door did not have a door closer.

Interview on 03/03/2020 at 1:41 PM with the Maintenance Director revealed he was not aware oxygen cylinders were being stored in the MRI Equipment Room. Further interview revealed the Maintenance Director was aware of the requirements for oxygen cylinder storage.



Reference: NFPA 99 (2012 Edition)

Handling of oxygen cylinders and manifolds is based on CGA G-4, Oxygen. Oxygen cylinders, containers, and associated equipment are protected from contact with oil and grease, from contamination, protected from damage, and handled with care in accordance with precautions provided under 11.6.2.1 through 11.6.2.4 (NFPA 99). 11.6.2 (NFPA 99)



11.3.4 Signs.
11.3.4.1
A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure.
11.3.4.2
The sign shall include the following wording as a minimum:

CAUTION:

OXIDIZING GAS(ES) STORED WITHIN

NO SMOKING


11.6.2 Special Precautions for Handling Oxygen Cylinders and Manifolds.
Handling of oxygen cylinders and manifolds shall be based on CGA G-4, Oxygen.
11.6.2.1
Oxygen cylinders, containers, and associated equipment shall be protected from contact with oil or grease by means of the following specific precautions:
(1) Oil, grease, or readily flammable materials shall not be permitted to come in contact with oxygen cylinders, valves, pressure reducing regulators, gauges, or fittings.
(2) Pressure reducing regulators, fittings, or gauges shall not be lubricated with oil or any other flammable substance.
(3) Oxygen cylinders or apparatus shall not be handled with oily or greasy hands, gloves, or rags.
11.6.2.2
Equipment associated with oxygen shall be protected from contamination by means of the following specific precautions:
(1) Particles of dust and dirt shall be cleared from cylinder valve openings by slightly opening and closing the valve before applying any fitting to the cylinder valve.
(2) The high pressure valve on the oxygen cylinder shall be opened slowly before bringing the apparatus to the patient or the patient to the apparatus.
(3) An oxygen cylinder shall not be draped with any materials such as hospital gowns, masks, or caps.
(4) Cylinder-valve protection caps, where provided, shall be kept in place and be hand-tightened, except when cylinders are in use or connected for use.
(5) Valves shall be closed on all empty cylinders in storage.
11.6.2.3
Cylinders shall be protected from damage by means of the following specific procedures:
(1) Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device.
(2) Oxygen cylinders shall not be stored near elevators or gangways or in locations where heavy moving objects will strike them or fall on them.
(3) Cylinders shall be protected from tampering by unauthorized individuals.
(4) Cylinders or cylinder valves shall not be repaired, painted, or altered.
(5) Safety relief devices in valves or cylinders shall not be tampered with.
(6) Valve outlets clogged with ice shall be thawed with warm - not boiling - water.
(7) A torch flame shall not be permitted, under any circumstances, to come in contact with a cylinder, cylinder valve, or safety device.
(8) Sparks and flame shall be kept away from cylinders.
(9) Even if they are considered to be empty, cylinders shall not be used as rollers, supports, or for any purpose other than that for which the supplier intended them.
(10) Large cylinders (exceeding size E) and containers larger than 45 kg (100 lb) weight shall be transported on a proper hand truck or cart complying with 11.4.3.1.
(11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.
(12) Cylinders shall not be supported by radiators, steam pipes, or heat ducts.
11.6.2.4
Cylinders and their contents shall be handled with care, which shall include the following specific procedures:
(1) Oxygen fittings, valves, pressure reducing regulators, or gauges shall not be used for any service other than that of oxygen.
(2) Gases of any type shall not be mixed in an oxygen cylinder or any other cylinder.
(3) Oxygen shall always be dispensed from a cylinder through a pressure reducing regulator.
(4) The cylinder valve shall be opened slowly, with the face of the indicator on the pressure reducing regulator pointed away from all persons.
(5) Oxygen shall be referred to by its proper name, oxygen, not air, and liquid oxygen shall be referred to by its proper name, not liquid air.
(6) Oxygen shall not be used as a substitute for compressed air.
(7) The markings stamped on cylinders shall not be tampered with, because it is against federal statutes to change these markings.
(8) Markings used for the identification of contents of cylinders shall not be defaced or removed, including decals, tags, and stenciled marks, except those labels/tags used for indicating cylinder status (e.g., full, in use, empty).
(9) The owner of the cylinder shall be notified if any condition has occurred that might allow any foreign substance to enter a cylinder or valve, giving details and the cylinder number.
(10) Neither cylinders nor containers shall be placed in the proximity of radiators, steam pipes, heat ducts, or other sources of heat.
(11) Very cold cylinders or containers shall be handled with care to avoid injury.