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Based on visual observation the facility failed to provide a fire alarm system that when activated properly provides positive alarm sequence, automatic occupant notification via audible and visual signals. When the building is equipped with life safety systems, that offer complete coverage, the occupants maintain a sense of security in an emergency. This deficiency has the potential to affect 25 of 60 residents.

Findings:

During the facility tour on 3/12/2019 between the hours of 9:00 am to 3:00 pm and on 3/13/2019 between the hours of 10:00 am to 4:00 pm it was observed on the eight floor section T, the fire alarm visible notification appliances were lacking synchronization.

Interview with the Facility Director revealed the facility was not aware the fie alarm system on the eighth floor had not been functioning properly.

Based on visual observation the facility failed to provide a fire alarm connected smoke detector in the proper location. The detectors offer a means of activating the fire alarm system to provide emergency notification to the occupants of the building. This deficiency has the potential to affect 30 of 60 residents.

Findings:

During the facility tour on 3/12/2019 between the hours of 9:00 am to 3:00 pm and on 3/13/2019 between the hours of 10:00 am to 4:00 pm it was observed the the on the fifth floor section M, two smoke detectors were within 36 inches from HVAC supply air diffusers.

NFPA 72:A.17.7.4.1 states, "Detectors should not be located in a direct airflow or closer than 36 in. (910 mm) from an air supply diffuser or return air opening. Supply or return sources larger than those commonly found in residential and small commercial establishments can require greater clearance to smoke detectors. Similarly, smoke detectors should be located farther away from high velocity air supplies."

Interview with the Facility Director revealed the facility was not aware that the smoke detectors were not installed in the proper location.

Based on visual observation, the facility failed to assure that areas with 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. 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 300 cubic feet are not required to be stored in an enclosure. 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. This deficiency has the potential to affect 0 of 10 patients


Findings:

During the facility tour on 3/12/2019, between the hours of 9:45 am to 11:30 am it was observed that the medical gas cylinders located on the backside of the first floor Touro Outpatient Surgery facility appeared to lack a proper one hour rated ceiling and interior 45 minute fire door with a self closing and self latching device. The total amount of medical gas within the room amounts 5,250 cubic feet of gas.

NFPA 99: 11.3.1* Storage for nonflammable gases equal to or greater than 85 m3 (3000 ft3) at STP shall comply with 5.1.3.3.2 and 5.1.3.3.3.

NFPA 99: 5.1.3.3.2* Design and Construction. Locations for central supply systems and the storage of positive-pressure gases shall meet the following requirements:
(1) They shall be constructed with access to move cylinders, equipment, and so forth, in and out of the location on
hand trucks complying with 11.4.3.1.1.
(2) They shall be secured with lockable doors or gates or otherwise secured.
(3) If outdoors, they shall be provided with an enclosure (wall or fencing) constructed of noncombustible materials with a minimum of two entry/exits.
(4) If indoors, they shall be constructed and use interior finishes of noncombustible or limited-combustible materials such that all walls, floors, ceilings, and doors are of a minimum 1-hour fire resistance rating.
(5)*They shall be compliant with NFPA 70, National Electrical Code, for ordinary locations.
(6) They shall be heated by indirect means (e.g., steam, hot water) if heat is required.
(7) They shall be provided with racks, chains, or other fastenings to secure all cylinders from falling, whether connected,
unconnected, full, or empty.
(8)*They shall be supplied with electrical power compliant with the requirements for essential electrical systems as described in Chapter 6.
(9) They shall have racks, shelves, and supports, where provided, constructed of noncombustible materials or limited-combustible materials.
(10) They shall protect electrical devices from physical damage.

Interview with the Facility Director revealed the facility was not aware that the stored medical gas cylinders were required to be in a rated area.