Regal Heights Rehabilitation and Health Care Center
October 7, 2016 Certification Survey

Standard Life Safety Code Citations

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least one hour. An atrium may be used in accordance with 8.2.5, 8.2.5.6, 19.3.1.1

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 7, 2016
Corrected date: October 21, 2016

Citation Details

Based on observation, it was determined that the facility did not ensure that the openings to the vertical shaftway containing boiler room exhaust flue were protected with appropriate self-closing fire rated doors. Reference is made to fire rated door protecting openings to the vertical shaftway on the 5th floor that was not made self-closing. The findings include: On (MONTH) 4, (YEAR) at 10:00 AM to 2:30 PM, it was observed that the openings to the vertical shaftway containing boiler room flue was provided with the fire rated doors . The door provided at the shaftway opening in the consultant office, on the 5th floor was not made self-closing as per 8.2.5.2. On (MONTH) 4, (YEAR) at approximately 11:15 AM, the facility's maintenance manager stated that all doors protecting the openings to the shaftway will be made self-closing. 711.2 (a)(1) 2000 NFPA 101

Plan of Correction: ApprovedOctober 27, 2016

I. Immediate Corrective Action:
A self-closing device was permanently installed on the fire rated door on vertical shaft way containing the boiler room flue in the 5th Floor Consultants Room.
II. Identification:
The Director of Environmental Service checked all fire rated doors on vertical shaft way and identified on the 2nd floor and 8th floor the need for installation of a self-closing device. Self-closing devices were permanently installed.
No other areas were identified.
III. Systemic Changes:
The established Preventive Maintenance & Scheduling program will be followed reflecting quarterly inspections of the fire rated doors and self-closing devices.
IV. QA Monitoring:
a.i.1. The Director of Environmental Service has been assigned the responsibility for monitoring the identified items.
a.i.2. The Director of Environmental Service will conduct an audit of all vertical shaft way doors to ensure the proper installation and functioning of self-closing devices on a monthly basis over the next quarter, then on a quarterly basis over the next year.
a.i.3. Audits with negative findings will have immediate corrective action by the Director of Environmental Service.
a.i.4. The Director of Environmental Service will report his inspections during the Quality Assurance Meetings for a period of one year.
V. Person Responsible for Corrective Actions:
Director of Environmental Service.

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 7, 2016
Corrected date: December 5, 2016

Citation Details

Based on observation, it was determined that the facility did not ensure that sprinklers in the building were located a minimum of 4 inches from a wall as per NFPA 13. Reference is made to the sprinkler installed within the central bathing area on the 6th floor and sprinkler in the toilet room on the 5th floor that were located closer than 4 inches from the wall. The findings include : On (MONTH) 4, (YEAR) at 10:00 AM to 2:30 PM, it was observed that the sprinklers located in the central bathing area in the vicinity of the recreation lounge on the 6th floor in the toilet room off the recreation lounge on the 5th floor that were installed approximately 1-1/2 inches from the wall instead of the minimum of 4 inches from the wall as per NFPA 13. On (MONTH) 4, (YEAR) at approximately 12:00 PM, the facility's maintenance manager stated that the sprinkler company will be contacted to reposition the sprinkler so as to be a minimum of 4 inches from the walls. 711.2 (a)(1) 2000 NFPA 101 1999 NFPA 13.

Plan of Correction: ApprovedOctober 27, 2016

I. Immediate Corrective Action:
The facility contracted with a Certified Licensed Sprinkler Vendor to relocate the identified deficiencies. Automatic Sprinkler pendants in the identified Central Bathing Rooms on the 6th and 5th Floors were relocated more than 4? from the sidewall to meet the requirements of NFPA 13 and NFPA 25.
II. Identification:
The Director of Environmental Service conducted a survey of all automatic sprinkler pendants to ensure pendants were located no more than 4? from the sidewall. No other areas were identified.
III. Systemic Changes:
The established Preventive Maintenance & Scheduling program will be followed reflecting inspection, testing, and maintenance of the automatic extinguishing systems.
IV. QA Monitoring:
a.i.1. The Director of Environmental Service has been assigned the responsibility for monitoring the identified items.
a.i.2. The Director of Environmental Service will conduct an audit of all automatic sprinkler pendants to ensure proper clearance from sidewalls on a monthly basis over the next quarter, then on a quarterly basis over the next year.
a.i.3. Audits with negative findings will have immediate corrective action by the Director of Environmental Service.
a.i.4. The Director of Environmental Service will report his inspections during the Quality Assurance Meetings for a period of one year.
V. Person Responsible for Corrective Action:
Director of Environmental Service

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Where required by section 19.1.6, Health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with section 9.7. Required sprinkler systems are equipped with water flow and tamper switches which are electrically interconnected to the building fire alarm. In Type I and II construction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specific areas where State or local regulations prohibit sprinklers. 19.3.5, 19.3.5.1, NPFA 13

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 7, 2016
Corrected date: December 5, 2016

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 NFPA13. Reference is made to the lack of sprinkler coverage for a number of areas in the building. Examples include: the storage room under the elevator machine room, the obstructed sprinkler in the toilet room off the recreation lounge on the 8th and 6th floors, lack of sprinklers in the passageway connecting the toilet room area to the bathing -tub area on the 7th, 6th, and 5th floors, and the obstructed sprinkler in the nurses' lounge on the 4th floor. The findings include: On (MONTH) 4, (YEAR) at 10:00 AM to 2:30 PM, it was observed that a number of areas in the building, including but not limited to the following, lacked sprinklers or the existing sprinklers were obstructed so as not to provide coverage for the entire protected area. (1)The storage room under the elevator machine room lacked sprinklers or the exception rule was not met by providing an appropriate self-closing fire rated door at the opening to the storage room. (2)The sprinklers provided in the toilet room off the recreation lounge on resident floors were obstructed by an approximately 10-12 inches high soffit on the 8th, 6th and 5th th floor toilet rooms off the recreation lounge. (3)The passageway connecting the toilet room section to the bathing-tub section within the central toilet/bathing/shower enclosure on resident floors, lacked sprinklers on the 7th, 6th, and 5th floors. (4)The sprinkler installed within the nurses' lounge area was obstructed by ceiling mounted lighting fixture at least on the 4th floor. Additionally, it was observed that sprinkler protection was missing in the recreational closets located on the first floor. In an interview on the the same day at approximately 10:45 a.m with the Director of Maintenance, he stated that this concern will be discussed with the Administrator. Subsequent interview at approximately 12:30 PM with the the facility's maintenance manager, he stated that the sprinkler company will be contacted to evaluate and provide automatic sprinklers in all areas of the building as per NFPA13. 711.2 (a)(1) 2000 NFPA 101 - 19.3.5.1 1999 NFPA 13 1999 NFPA 80

Plan of Correction: ApprovedOctober 27, 2016

I. Immediate Corrective Action:
Automatic Sprinklers were relocated in the identified areas lacking coverage or obstructions to meet NFPA 13 and NFPA 25 requirements, by the facility contracted Certified Licensed Sprinkler Vendor.
1) A self-closing device was also added to the fire rated door in the Storage Room under the Elevator Machine Room. The fire rated door self-closes and positive latches, as required.
2) Automatic Sprinklers were relocated in the identified Bathrooms off the Recreation Lounges on the 8th, 6th, and 5th Floors to provide 100 percent coverage in the room without obstructions.
3) Automatic Sprinklers were relocated in the identified Bathing Suites on the 7th, 6th, and 5th Floors to provide 100 percent coverage in the room without obstructions.
4) The automatic sprinkler obstructed by light fixture in the 4th Floor Nurses Lounge was relocated with no obstructions.
5) Automatic sprinkler protection was provided in the identified Recreational Closets on the 1st Floor, but was not observed during survey due to lighting issues.
II. Identification:
1) The Director of Environmental Service checked the elevator Machine Room for other storage rooms lacking self-closing fire rated doors. None were identified.
2) The Director of Environmental Service conducted a survey of areas not protected by an automatic sprinkler system or automatic sprinkler pendants that were obstructed.
3) Recreation Lounge Bathrooms were checked for obstructions and automatic sprinklers. The 4th, 3rd, and 2nd Floors were also identified and relocated.
4) The Bathing Suites were checked for coverage and automatic sprinklers. The 8th, 4th, 3rd, and 2nd Floors were identified and relocated.
5) The Nursing Lounge was checked for any obstructions; the 3rd, 5th and 6th floors were identified and relocated.
6) No other areas were identified.
7) Systemic Changes:
The facility contracted with a Certified Licensed Sprinkler Vendor to relocate the identified deficiencies. The established Preventive Maintenance & Scheduling program will be followed reflecting inspection, testing, and maintenance of the automatic extinguishing systems.
8) QA Monitoring:
a.i.1. The Director of Environmental Service has been assigned the responsibility for monitoring the identified items.
a.i.2. The Director of Environmental Service will conduct an audit of all automatic sprinklers to ensure automatic sprinklers are properly installed and are unobstructed on a monthly basis over the next quarter, then on a quarterly basis over the next year.
a.i.3. Audits with negative findings will have immediate corrective action by the Director of Environmental Service
a.i.4. The Director of Environmental Service will report his inspections during the Quality Assurance Meetings for a period of one year.
9) Person Responsible for Corrective Action:
Director of Environmental Service