Jeanne Jugan Residence
December 16, 2016 Certification Survey

Standard Life Safety Code Citations

K307 NFPA 101:COOKING FACILITIES

REGULATION: Cooking Facilities 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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 16, 2016
Corrected date: February 10, 2017

Citation Details

Based on observation, it was determined that the facility did not ensure that the fire protection system for the cooking equipment was maintained in accordance with NFPA96. Reference is made to the sprinkler nozzles protecting the Vulcan brand oven that were grease encrusted. The findings include: On (MONTH) 14, (YEAR), at 9:30 AM to 3:00 PM, during the recertification survey, it was observed that the facility's cooking equipment located in the kitchen area was provided with the wet chemical type fire protection system. The spray nozzles installed in connection with this fire protection system for the Vulcan brand oven were noted to be encrusted with grease. All components of the fire protection system for the cooking equipment must be inspected, maintained and replaced as per manufacturer instructions and as per NFPA96. On (MONTH) 14, (YEAR), at approximately 10:15 AM, the facility's Director of Maintenance stated that the contracted company will be contacted to replace the grease encrusted nozzles protecting the Vulcan brand oven. 711.2 (a)(1) 2012 NFPA 101 2011 NFPA 96

Plan of Correction: ApprovedJanuary 20, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** All components of the fire protection system for the cooking equipment will continue to be inspected, maintained and replaced as per manufacturer instructions and as per NFPA96.
Facility has documentation that the fire protection system for the cooking equipment was inspected and maintained on [DATE], (YEAR) and [DATE], (YEAR) by Reliable Fire Protection.

A schedule will be created for monthly inspection of the range hood fire extinguishing system. A log will be established for recording the date and the initials of the person performing the inspection so that that vendor may be contacted as necessary if equipment needs to maintained in between regularly scheduled visits so as to meet code requirements.
The log will be made available for review at QA meetings.
The Director of Maintenance will ensure that this is done by [DATE], (YEAR).

K307 NFPA 101:DOORS WITH SELF-CLOSING DEVICES

REGULATION: Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 16, 2016
Corrected date: February 10, 2017

Citation Details

Based on observation, it was determined that the facility did not ensure that the doors protecting openings to hazardous areas were only held open with release devices that comply with 7.2.1.8.2, and that would automatically close the doors upon activation of the facility's fire alarm system, as stated under 19.2.2.2.7. Reference is made to the doors to the storage rooms that were held open with devices other than the automatic release devices that would activate upon the activation of the facility's fire alarm system. Examples were: storage room #C3; storage room off the auditorium; and the storage room off the kitchen area. The findings include: On (MONTH) 14, (YEAR), at 9:30 AM to 3:00 PM, during the re-certification survey, it was observed that the facility doors to the following hazardous areas (storage rooms) were held open with other than approved door release devices that would automatically release the doors upon activation of the facility's fire alarm systems, as per 7.2.1.8.2. Examples include: - The door to storage room #C3 was held open with a clip type device installed at the rear of the door. This device is not an approved device that would automatically release the doors upon activation of the facility's fire alarm system. - The door to the storage room off of the auditorium was held open by means of a metal stand. This device is not an approved device that would automatically release the door upon activation of the facility's fire alarm system. - The door to the main dietary storage room off the kitchen area, was held open by means of a clip type device installed at the rear of the door. This door hold open device is not an approved device that would automatically release the door upon activation of the facility's fire alarm system. On (MONTH) 14, (YEAR), at approximately 11:00 AM, the facility's Director of Maintenance stated that all inappropriate door hold open devices were being removed. 711.2(a)(1) 2012 NFPA 101

Plan of Correction: ApprovedJanuary 20, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Facility doors to hazardous areas (storage rooms) will only be held open with release devices that comply with 7.2.1.8.2, and that would automatically close the doors upon activation of the facility's fire alarm system, as stated under 19.2.2.2.7. No other devices will be used to hold doors open.
Deficient devices will be removed by [DATE], (YEAR).

Sign will be posted near door to storage room off of the auditorium with instructions that door must not be propped open. Sign will be posted by [DATE], (YEAR).
A schedule will be implemented for annual inspection of all doors in the facility to ensure they are in compliance with 2012 edition of the Life Safety Code of the NFPA. A log of all doors in the entire facility will be created to document the inspection, date and initials of the person completing the inspection. The log will be made available for review at the Quality Assurance Meetings.
In addition, an in-service will be given to all department heads to ensure compliance.
The director of maintenance will provide the in-service and will ensure that this regulation is respected.

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: December 16, 2016
Corrected date: February 10, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, it was determined that the facility did not ensure that the doors protecting the openings to the sprinklered hazardous areas were made self-closing and latching in their frames. Reference is made to the doors to the storage room doors that were not made self-closing and/or positive latching. Examples were: The door to storage room [ROOM NUMBER], door to general storage room on the 4th floor; door to storage room [ROOM NUMBER]B; and door to storage room [ROOM NUMBER]. The findings include: On (MONTH) 14,2016, at 10:00 AM to 2:00 PM, it was observed that the facility hazardous areas (storage rooms) were protected with an automatic fire extinguishing system. The doors protecting the openings to a number of storage rooms were not made self or automatic closing and/or positively latching. Examples include: - The door to storage room [ROOM NUMBER] was not latching in its frame. - The door to the storage room located on the 4th floor was not made self-closing or automatic closing. - The door to storage room [ROOM NUMBER]B was not made self-closing or automatic closing. - Storage room [ROOM NUMBER] was provided with a two leaf door. The doors leaves were not kept latched as designed. The door leaves over-lapped one another, preventing them from latching into each other as designed. On (MONTH) 14, (YEAR), at approximately 12:00 PM, the facility's Director of Maintenance stated that all doors to hazardous areas will be made self-closing and positive latching 711.2 (a)(1) 2012 NFPA 101

Plan of Correction: ApprovedJanuary 20, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The doors protecting the openings to storage rooms will be self or automatic closing and/or positively latching by [DATE], (YEAR).
A schedule will be created for annual inspection of all doors in the facility to ensure they are in compliance with the 2012 edition of the Life Safety Code of the NFPA. A log will be maintained with date of inspection and initials of the person having inspected the door. The log will be made available for review at the Quality Assurance Meetings.
An in-service will be given to all department heads to ensure compliance with the regulations for the doors.
The director of maintenance will provide the in-service and will be responsible for maintaining logs and ensuring compliance.

K307 NFPA 101:MEANS OF EGRESS - GENERAL

REGULATION: Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 16, 2016
Corrected date: February 10, 2017

Citation Details

Based on observation, it was determined that the facility did not ensure that the exit access corridors were maintained free of storage that would interfere with the safe usage of the corridors during a fire or other emergency. Reference is made to the stored cartoned supplies and other miscellaneous supplies in the exit access corridor in the vicinity of the central storage room. The findings include: On (MONTH) 14, (YEAR), at 9:30 AM to 3:00 PM, during the re-certification survey, it was observed that the facility had stored cartoned supplies and other miscellaneous supplies in the exit access corridor in the vicinity of the main storage room in the basement. Such stored items in the exit access corridor would make the corridor impassable during a fire or other emergency. All means of egress are to be maintained free of any storage that would interfere with the safe usage of the means of egress by the building occupants. On (MONTH) 14, (YEAR), at approximately 10:30 AM, the facility's Director of Maintenance stated that the stored supplies were being removed from the egress corridor. 711.2(a)(1) 2012 NFPA 101

Plan of Correction: ApprovedJanuary 20, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corridors leading to means of egress will continuously be maintained free of all obstructions to full use in case of emergency.

Signs will be posted in basement corridors instructing staff to keep areas free of storage.
A log will be created and maintained for daily monitoring of corridors. Log will be completed by security guards during their rounds and will be made available for QA meetings.

The director of maintenance will ensure that this directive is followed.
In-service will be given by the director of maintenance. This will be completed by [DATE], (YEAR).

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: December 16, 2016
Corrected date: February 10, 2017

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 and NFPA 13. Reference is made to the lack of sprinkler coverage for a number of areas in the building. Examples were: an enclosed area used as a plenum off of the mechanical room in the basement; the main electrical room #C11-A, that was being used for storage; and a large area located off of the auditorium that was used for storage. The findings include: On (MONTH) 14, (YEAR), at 9:30 AM to 3:00 PM, during the re-certification survey, it was observed that a number of areas in the building, including but not limited to, the following areas lacked sprinklers, or the existing sprinklers were obstructed so as not to provide coverage for the entire protected area: (1) A large enclosed area that was used asa plenum for the multiple air handling equipment off of the mechanical room in the basement, lacked sprinklers. The enclosed area had multiple doors leading to the mechanical room and was accessible for storage. The doors protecting the openings to the mechanical room from the plenum area were not labeled and rated doors. (2) The central electrical room #C11-A in the basement lacked sprinklers. The room was being used for the storage of cartoned supplies, utility carts and storage shelving. (3) A section of the storage area, measuring approximately 3 ft x 30 ft, off the auditorium #112 on the first floor, that was used for the storage of cartoned supplies and cartons of decorations, lacked sprinkler coverage. The existing sprinklers were obstructed by the solid type ceiling hung curtain so as not to provide coverage for the area used for storage. On (MONTH) 14,2016 at approximately 12:30 PM, the facility's Director of Maintenance stated that the sprinkler company will be contacted to evaluate the conditions, and either provide sprinklers for the identified areas or comply with the exception rules stated in NFPA 13. 711. 2(a)(1) 2012 NFPA 101 2010 NFPA 13

Plan of Correction: ApprovedJanuary 20, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** All required areas in the building will be protected by an automatic sprinkler system in accordance with section 9.7 and NFPA 13.
1. The plenum area will not be used for storage. All doors to the plenum area will be replaced with labeled and rated doors. This will be completed by [DATE], (YEAR).
2. The central electrical room #C11-A in the basement will not be used for storage. Signs will be posted in this room and in-service will be provided by director of maintenance to ensure compliance. This will be completed by [DATE], (YEAR). A log will be maintained on monthly audits of this central electrical room. The log will be made available for review at the QA meetings.
3. An approved mesh type fire proof curtain will be installed in the section of the storage area, measuring approximately 3 ft x 30 ft, off the auditorium #112 on the first floor so that this area may continue to be used for storage.
The Director of Maintenance will ensure that these are completed by [DATE], (YEAR).

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: December 16, 2016
Corrected date: February 10, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, it was determined that the facility did not ensure that all automatic sprinkler piping and automatic sprinklers were maintained in accordance with NFPA13 and NFPA 25. Reference is made to multiple armover sections of the sprinkler piping in the boiler room and the storage room that lacked the required supporting hanger; a number of concealed sprinklers in the building that lacked their cover plates; and the painted/sprayed sprinkler head in the main storage room in the basement. The findings include: On (MONTH) 14, (YEAR), at 9:30 AM to 3:00 PM, during the re-certification survey, the following was observed : (1) A number of armover sections of the sprinkler piping exceeded the permitted length of the unsupported armover piping to the last sprinkler head from the last hanger,as per NFPA13, section 14-14.2.3.2 and 14-14.2.3.4. In the boiler room, in the main storage room, and in residents' storage room in the basement, the greater than 2 feet long sprinkler armover piping to the last sprinkler from the last hanger on the one inch line, lacked supporting hangers. The unsupported length of the armover sections of sprinkler piping ranged from approximately 4 feet to 7 feet long from the last sprinkler to the last hanger. (2) A number of concealed sprinklers lacked their cover plates. Examples include: the corridor in the vicinity of the storage room in the basement; toilet room [ROOM NUMBER]; toilet room [ROOM NUMBER]; and toilet room [ROOM NUMBER]. (3) At least one sprinkler head in the main storage area was covered with white spray-on material. On (MONTH) 14, (YEAR) at approximately 11:30 AM, the facility's Director of Maintenance stated that the sprinkler company will be contacted to evaluate the situation and provide additional supporting hangers for the oversize armovers, provide cover plates for the concealed sprinklers, and replace the spray coated sprinkler head. 711.2 (a)(1) 2012 NFPA 101 2010 NFPA 13

Plan of Correction: ApprovedJanuary 20, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility will ensure that all automatic sprinkler piping and automatic sprinklers are maintained in accordance with NFPA13 and NFPA 25.
1. An inspection of the facility will be conducted to identify all areas in need of support hangers. Hangars will be added where needed and results documented. This will be completed by [DATE], (YEAR). This will be ensured by the director of maintenance.
2. Monthly inspections of concealed sprinkler heads will be performed to ensure that they have cover plates. A log will be maintained of these inspections. The director of maintenance will ensure compliance. This will completed by [DATE], (YEAR).
3. There will be no white spray-on material on the sprinkler heads. The director of maintenance will ensure compliance. This will completed by [DATE], (YEAR).
The Director of Maintenance will ensure that these rectifications are completed by [DATE], (YEAR).