St Patricks Home
February 28, 2018 Certification/complaint Survey

Standard Life Safety Code Citations

K307 NFPA 101:HAZARDOUS AREAS - ENCLOSURE

REGULATION: Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 6, 2018
Corrected date: May 8, 2018

Citation Details

Based on observation, it was determined that the facility did not ensure that doors to hazardous areas were provided with appropriate latching mechanisms. Reference is made to the doors to the soiled linen storage room and the gift shop that lacked latching devices. The findings include: On (MONTH) 5,2018 and (MONTH) 6,2018 between 9:30 AM and 3:00 PM, during the recertification survey, it was observed that hazardous areas in the building were provided with an automatic extinguishing system. The doors to the soiled linen storage room in the basement, and the door to the gift shop on the first floor lacked latching devices to keep the doors tightly closed in their frames. On (MONTH) 6,2018 at approximately 12:45 PM, the facility's Assistant Director of Engineering stated that doors to hazardous areas will be provided with latching devices. 711.2 (a)(1) 2012 NFPA 101

Plan of Correction: ApprovedMarch 22, 2018

Preparation and execution of this Plan of Correction does not constitute admission or agreement by the Provider. The Plan of Correction is prepared and executed solely because it is required by the provisions of Federal and State Laws.
No residents were affected by this deficiency.
Soiled Linen Storage Room located on the Ground Floor (Basement) the door latching device was replaced.
Completed: 3/7/2018
Gift Shop located on the 1st Floor the door latching device was replaced.
Completed: 3/15/2018
The facility has implemented a door maintenance program which includes positive latching devices for all corridor doors and doors leading to hazardous areas in compliance with the NFPA Standard. The maintenance program will be completed monthly for three months and going forward quarterly.
Findings will be reviewed at the Monthly QA/Quarterly QAA Meetings.
Completed:3/15/2018
Responsible Person: Director of Engineering/Designee

K307 NFPA 101:PORTABLE FIRE EXTINGUISHERS

REGULATION: Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 6, 2018
Corrected date: May 8, 2018

Citation Details

Based on observation, it was determined that the facility did not ensure that all portable fire extinguishers were installed and maintained in accordance with NFPA10- Standard for Portable Fire Extinguishers. Reference is made to the wet chemical type portable fire extinguisher located in the 1st floor coffee shop, that was installed more 5 feet above the floor. The findings include: On (MONTH) 5, (YEAR) and (MONTH) 6, (YEAR), between 9:30 AM and 3:00 PM,during the recertification survey, it was observed that the facility had provided a wall mounted wet chemical type portable fire extinguisher in the 1st floor coffee shop. The top of the extinguisher measured approximately 6 feet above the floor, instead of the maximum of 5 feet above the floor, as per 6.1.3.8 of NFPA 10. On (MONTH) 6, (YEAR) at approximately 1:30 PM, the facility's Assistant Director of Engineering stated that the extinguisher was being lowered to the allowable height above the floor. 711.2 (a)(1) 2012 NFPA 101 2010 NFPA 10

Plan of Correction: ApprovedMarch 22, 2018

Preparation and execution of this Plan of Correction does not constitute admission or agreement by the Provider. The Plan of Correction is prepared and executed solely because it is required by the provisions of Federal and State Laws.
No residents were affected by this deficiency.
Coffee Shop 1st Floor the wall mounted wet chemical portable extinguisher has been lowered to the proper height above the floor. Completed: 3/7/2018
Engineering staff has been In-serviced regarding code/requirement for the maximum height of wall mounted fire extinguishers. Completed: 3/20/2018
The facility has implemented a monthly maintenance program to insure that all wall mounted fire extinguishers height are at the maximum of 5 feet above the floor in compliance with the NFPA Standard.
Findings will be reviewed at the Monthly QA/Quarterly QAA Meetings.
Completed: 3/20/2018
Responsible Person: Director of Engineering/Designee

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

REGULATION: Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 6, 2018
Corrected date: May 8, 2018

Citation Details

Based on observation, it was determined that the facility did not ensure that all areas in the building were protected by an automatic sprinkler system in accordance with section 9.7. Reference is made to the lack of sprinkler coverage for a number of areas in the building. Examples include: the television room off the recreation area on the first floor; the alcove area off the gift shop; and the tub room on the 3rd floor. The findings include: On (MONTH) 5, (YEAR) and (MONTH) 6, (YEAR), between 9:30 AM and 3:00 PM, during the recertification survey, it was observed that a number of areas in the building, including the following areas, lacked sprinkler coverage in accordance with NFPA 13. (1) In the television room off the 1st floor recreation area, the sprinkler was not located at least one half of the allowable distance between sprinklers, as per table 8.6.2.2.1. The sprinkler was located approximately 9 feet from the wall instead of 7½ feet from the wall. (2) An alcove area off of the gift shop that was used for storage, was not protected with sprinklers. The existing sprinkler was obstructed by the turn of wall, so as not to provide coverage for the alcove area. (3) On the 3rd floor, the shower stall off the centralized tub room area was not protected with sprinklers. The existing sprinkler was obstructed by the partitioning wall, so as not to provide coverage for the entire protected area. On (MONTH) 6, (YEAR) at approximately 12:30 PM, the facility's Assistant Director of Engineering stated that the sprinkler consultants will be contacted to evaluate and install sprinklers in all areas of the building. 711.2 (a)(1) 2012 NFPA 101 2012 NFPA 13

Plan of Correction: ApprovedApril 2, 2018

Preparation and execution of this Plan of Correction does not constitute admission or agreement by the Provider. The Plan of Correction is prepared and executed solely because it is required by the provisions of Federal and State Laws.
No residents were affected by this deficiency.
Recreation Room located on the 1st Floor inside Television/Copy Room the existing sprinkler head was relocated to the proper footage from the wall.
Completed: 3/14/2018
Gift Shop located on the 1st Floor storage area alcove the existing sprinkler head was relocated to provide coverage to the alcove area.
Completed: 3/14/2018
Tub Room located on the 3rd Floor the shower stall the existing sprinkler head was relocated to provide coverage to the shower stall area.
Completed: 3/14/2018
A contracted automatic fire sprinkler provider/Engineer will conduct an assessment of the existing automatic fire sprinkler system heads. Vendor to ensure that the sprinkler heads are located properly and providing the proper protection in accordance with NFPA Standard. Any additional heads found will be relocated as per the NFPA Standard.
Completed By: (MONTH) 4, (YEAR)
Findings will be reported at the (MONTH) (YEAR) Monthly QA/June (YEAR) Quarterly QAA Meetings.
Responsible Person: Director of Engineering/Designee

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

REGULATION: 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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 6, 2018
Corrected date: May 8, 2018

Citation Details

Based on observation, it was determined that the facility did not ensure that the automatic sprinklers were installed and maintained in accordance with NFPA 25. Reference is made to the lack of cover plates for concealed sprinklers in the kitchen and in the female locker room area in the basement. The findings include: On (MONTH) 5,2018 and (MONTH) 6, (YEAR), between 9:30 AM and 3:00 PM, during the recertification survey, it was observed that the concealed sprinklers located in the steam kettle area off the kitchen, and in the female locker room in the basement, lacked cover plates. On (MONTH) 6, (YEAR) at approximately 12:30 PM the facility's Assistant Director of Engineering stated that the cover plates will be provided for all concealed sprinkler heads. 711.2 (a)(1) 2012 NFPA 101 2912 NFPA 13 2011 NFPA 25

Plan of Correction: ApprovedMarch 22, 2018

Preparation and execution of this Plan of Correction does not constitute admission or agreement by the Provider. The Plan of Correction is prepared and executed solely because it is required by the provisions of Federal and State Laws.
No residents were affected by this deficiency.
Kitchen located on the Ground Floor (Basement) the sprinkler head located by the steam kettle within the kitchen area the concealed sprinkler head cover was replaced.
Completed: 3/7/2018
Female Locker Room located on the Ground Floor (Basement) the concealed sprinkler head cover was replaced.
Completed: 3/7/2018
To ensure that all sprinkler head concealed covers are properly installed in compliance with the NFPA Standard the engineering staff will conduct monthly rounds for three months and going forward quarterly.
Findings will be reviewed at the Monthly QA/Quarterly QAA Meetings.
Completed: 3/7/2018
Responsible Person: Director of Engineering/Designee