Norwegian Christian Home and Health Center
May 26, 2017 Certification Survey

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

REGULATION: Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 26, 2017
Corrected date: July 15, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, it was determined that the facility did not ensure that all electrical equipment used for resident care were maintained and tested in accordance with NFPA 99. Reference is made to the lack of documentation to show that the resident use electric beds, nebulizers, commercial hair dryers, mattress pumps and oxygen concentrators were maintained and tested for safety as per manufacturer instructions and/or as per policies and protocols established by the facility or the contracted agency. The findings include: On (MONTH) 22, (YEAR) between 10:30 AM to 2:30 PM, during the annual recertification survey, it was observed that the facility had provided a number of resident care electrical equipment in the resident room or in storage for the resident use, as needed. An interview with the facility's Director of Facilities and review of facility maintenance records revealed that the facility lacked appropriate documentation to show that all resident care electric equipment, including but not limited to the following, were maintained and tested in accordance with established policies and protocols. (1) In resident rooms #310, the InVacare electric beds had no inspection tags affixed to beds, as per facility policy. The facility had not retained any maintenance and care manuals by the manufacturer of the beds. Also, the facility had not established any policies and protocols for the maintenance, type of tests and intervals of testing for the safety of electric beds. (2) In the beauty parlor, the two commercial type hair dryers had last inspection tags of (MONTH) 17, 2014. The facility had not established any inspection/testing intervals for the electric hair dryers. (3) An electric Pulmo-Aide nebulizer provided in room [ROOM NUMBER], had no inspection tag affixed to the equipment, nor the facility had any written record for the testing and maintenance of the nebulizer. (4) The Covidien brand electric feeding pump located in the nurses' equipment room had no inspection tag or written record for the testing and maintenance. (5) The electric mattress pump located in room [ROOM NUMBER], lacked an inspection tag or written record for the testing and maintenance. On (MONTH) 22, (YEAR), at approximately 1:30 PM, the facility's Director of Facilities stated that the manufacturers of resident electric beds and other resident electrical equipment used by the facility will be contacted to provide care manuals for such equipment. The Director further stated that policies and protocols for the safe maintenance and testing of all resident care electrical equipment in the facility,based on manufacturers' recommendations,will be established and followed and records maintained, as per NFPA 99. 711.2 (a)(1) 2012 NFPA 101 2012 NFPA 99

Plan of Correction: ApprovedJuly 3, 2017

? The Director of facilities performed the immediate corrective actions:
? A complete inventory of all patient care equipment was performed and recorded (completed 6/29/17)
? Manufacturer?s service manuals were obtained for all patient care equipment in use and is now maintained in the maintenance department. (completed 6/29/17)
? Manufacturer?s recommendations for service and maintenance is being added to the maintenance inventory review tool (to be completed by 7/15/17)
? All maintenance staff will be educated on the updated tool by 7/15/17.
? Inspection, tagging and preventative maintenance was added to the maintenance staff work assignments and all maintenance staff have been re-educated on it. (Completed 6/29/17)
? Policies were developed for General Electrical Safety and Bio-Medical Engineering program. All maintenance staff were in-serviced on the new policies. ( completed 6/22/17)
? The Director of facilities performed a comprehensive inspection and all devices and equipment are appropriately tagged and scheduled as per the manufacturer?s recommendations. ( completed 6/22/17)
? The Director of facilities and/or maintenance staff will inspect, tag and schedule equipment prior to placing in resident?s rooms or in a resident care area.
? To ensure compliance the Director of Facilities will perform inspections of equipment using a standardized audit tool monthly until 100% compliance is in achieved and then quarterly .The results will be reported at the monthly QAPI meeting.
? The Director of facilities will be responsible for compliance

K307 NFPA 101:HVAC

REGULATION: HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications. 18.5.2.1, 19.5.2.1, 9.2

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 26, 2017
Corrected date: June 22, 2017

Citation Details

Based on observation, it was determined that the facility did not ensure that service openings to fire duct dampers were identified with letters, in accordance with 2-3.4.2, NFPA 90. Reference is made to the lack of identification signs for the fire/smoke damper service openings located in the vicinity of the nursing station on the 3rd and 4th floors. The findings include: On (MONTH) 22, (YEAR) between 10:30 AM to 2:30 PM, during the recertification survey of the facility, it was observed that the facility had provided covered service openings for the fire/smoke damper installed in connection with the building ventilation duct system. The damper service openings located in the vicinity of the nursing station on the 3rd and 4th floors lacked identification signs. All service openings to fire/smoke dampers must be identified with letters having a minimum height of 1/2 inches,as per 2-3.4.2, NFPA 90A. On (MONTH) 22, (YEAR) at approximately 12:30 PM, the facility's Director of Facilities stated that all service openings to the fire/smoke dampers will be identified with letters,as per NFPA 90A. 711.2 (a)(1) 2012 NFPA 90 A

Plan of Correction: ApprovedJuly 12, 2017

? The Director of Facilities immediate corrective actions were:
? The Director of facilities conducted an inspection of all 3 nursing units and identified the ½ inch letters were needed on all 3 units.
? The required lettering was added on all 3 units. Completed 6/22/17
? In order to ensure compliance the Director of Facilities will conduct monthly inspections of the service opening using a standardized audit tool until 3months of 100% compliance is met then will conducted quarterly and report findings at the monthly QAPI meeting.
? The Director of facilities will have overall responsibility for compliance.

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: May 26, 2017
Corrected date: July 15, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: YOUSAF, MOHAMMAD Based on observation, it was determined that the facility did not ensure that all areas in the building were protected by an approved automatic sprinkler system in accordance with section 9.7 and NFPA 13. Reference is made to the lack of a automatic sprinkler system in a number of areas in the building, examples include: the large alcove space of the generator room; the equipment room on the 4th floor; an obstructed sprinkler in room [ROOM NUMBER]; and the large concealed space in the vicinity of the consultation office on the 4th floor; and lack of appropriate identification signs for a number of sprinkler control valves. The findings include: On (MONTH) 22, (YEAR) between 10:30 AM to 2:30 PM, during the annual recertification 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 areas: (1) In the generator room a large recessed area (approximately 7 feet deep), containing motorized louvers, lacked sprinklers. (2) A large ( 4 ft x 4 ft) enclosed concealed space in the vicinity of the consultation office on the 3rd and 4th floors, lacked sprinklers. A portable electric fan was observed stored in the enclosed space on the 4th floor. (3) In the equipment storage room across from room [ROOM NUMBER], sprinkler coverage was lacking under the 3 ft x 3 ft duct enclosure. The existing sprinkler was obstructed by an 11 inches high soffit, so as not to provide coverage for the duct enclosure. (4) The sprinkler head was obstructed by the solid type curtain in the toilet room/shower room off room [ROOM NUMBER], so as not to provide coverage within the shower stall. (5) A number of sprinkler control valves and/or drain valves lacked identification signs to indicate the section of the sprinkler system they control, examples were : the two sprinkler valves in the meter room and the drain valve in resident storage room, both in the basement, as well as at least one sprinkler valve and a drain valve located in the old meter room, also in the basement. On (MONTH) 22,2017 at approximately 12:00 PM, the facility's Director of Facilities stated that the sprinkler company will be contacted to evaluate and install sprinklers in all areas of the building and provide appropriate identification signs for sprinkler valve and drain valves. 711. 2 (a)(1) 2012 NFPA 101 2012 NFPA 13

Plan of Correction: ApprovedJuly 5, 2017

? The Director of facilities performed an inspection and determined the generator room and the equipment storage room on the 4th floor required sprinklers to be added.
? Contracted with A&F Fire Protection Company to install the sprinklers- to be completed 7/15/17.
?The sprinkler coverage impeded by solid privacy curtains is being replaced with mesh topped shower curtains to be completed by 7/15/17.
? The concealed space identified on the 4th floor has had the portable electric fan removed. This space has been permanently sealed and will no longer be accessible for storage purposes. Completed 7/5/17.
? 6 sprinkler valves in the meter room were labeled correctly to indicate the section of the sprinkler system serviced by them. Completed 5/25/17.
? Drain valve in the resident storage room was relabeled for riser service. Completed 5/25/17
? The Director of Facilities performed an inspection and determined no other areas were affected by the deficient practice.

? The Director of facilities will ensure completion of the installation of sprinklers in the areas identified.
? In order to ensure compliance a sprinkler test will be conducted monthly with the use of a standardized audit tool until 100% compliance is achieved for 3 consecutive months then be conducted quarterly and results will be reported to the QAPI committee at its monthly meeting.
? The Director of Facilities will be responsible for compliance.

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: May 26, 2017
Corrected date: June 30, 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 automatic sprinklers and sprinkler piping were maintained in accordance with NFPA 13. Reference is made to the lack of supporting hangers for the excessive length of the armover section or the branch line piping system located within stair A at basement level, and the wheelchair storage room in the basement; and the lack of cover plates for the concealed sprinklers in the clean linen storage room in the basement. The findings include: On (MONTH) 22 (YEAR) between 10:30 AM to 2:30 PM, during the re-certification survey of the facility, the following was observed: (1) A supporting hanger was lacking for the greater than two feet long end of the armover section of the sprinkler piping from the last sprinkler to the last hanger, in the exit stairway A at basement level, as per 4-14.2.3.2 and 4-14.2.3.4, NFPA 13. (2) A supporting hanger was lacking for the greater than three feet long end of the branch line, from the last sprinkler to the last hanger of the branch line, in the wheelchair storage room in the basement. (3) The cover plates were lacking for the concealed sprinklers in the clean linen storage room and in room [ROOM NUMBER]. On (MONTH) 22,2017 at approximately 11:30 AM,the facility's Director of Facilities stated that supporting hangers will be installed at the excessive length of armovers and the sprinkler branch lines. The Director further stated that cover plates will be installed for all concealed sprinklers. 711.2 (a)(1) 2012 NFPA 101 2010 NFPA 13

Plan of Correction: ApprovedJuly 3, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** ? The Director of facilities: The immediate corrective actions were:
? A supportive hanger was installed on the section of sprinkler piping in Exit Stairway A at the basement level completed 6/30/17
? A supportive hangar was installed on the greater than three foot section of sprinkler piping branch line in the wheelchair storage room completed 6/30/17.
? Cover plates were installed in the concealed sprinklers in the clean linen storage room and in room [ROOM NUMBER] completed 6/30/17.
? The Director of facilities performed and inspection and determined no other areas were affected by the deficient practice. Completed 6/22/17.
? In order to ensure compliance monthly inspections of the sprinkler arm over branch lines will be conducted with the use of a standardized audit tracking tool and reports will be reported at the monthly QAPI meeting. When 100% compliance is met for 3 consecutive months then the audit will be conducted quarterly.
? The Director of facilities management will be responsible for compliance.