2014-10-01
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Inspection Results
Recertification/State Licensure/Life Safety Code - (14-OCT-10)
Facility failed to meet the following Requirement(s):Date CorrectedLevel of HarmResidents Affected
Exit access is arranged so that exits are readily accessible at all times in accordance with section 7.1. 19.2.1 26-NOV-10No actual Harm with potential for More than minimal harm that is not immediate jeopardyMany
Emergency lighting of at least 1 hour duration is provided in accordance with 7.9. 19.2.9.1. 26-NOV-10No actual Harm with potential for More than minimal harm that is not immediate jeopardyMany
A fire alarm system with approved components, devices or equipment is installed according to NFPA 72, National Fire Alarm Code, to provide effective warning of fire in any part of the building. Activation of the complete fire alarm system is by manual fire alarm initiation, automatic detection or extinguishing system operation. Pull stations in patient sleeping areas may be omitted provided that manual pull stations are within 200 feet of nurse's stations. Pull stations are located in the path of egress. Electronic or written records of tests are available. A reliable second source of power is provided. Fire alarm systems are maintained in accordance with NFPA 72 and records of maintenance are kept readily available. There is remote annunciation of the fire alarm system to an approved central station. 19.3.4, 9.6 26-NOV-10No actual Harm with potential for More than minimal harm that is not immediate jeopardyMany
Heating, ventilating, and air conditioning comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2 26-NOV-10No actual Harm with potential for More than minimal harm that is not immediate jeopardyMany
Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2 26-NOV-10No actual Harm with potential for More than minimal harm that is not immediate jeopardyMany
(95) Ventilation requirements given in Table I-Ventilation Requirements shall be met II/III TABLE I VENTILATION REQUIREMENTS Area Designation (Pressure Relationship to Adjacent Areas, Minimum Air Changes of Outdoor Air Per Hour Supplied to Room) Patient Area Corridor (P, Optional) Physical Therapy (N, 2) Occupational Therapy (N, 2) Soiled Work Room or Soiled Holding (N, 2) *Toilet Room (N, Optional) Bathroom (N, Optional) Janitors' Closet(s) (N, Optional) Linen and Trash Chute Room (N, Optional) Food Preparation Center (E, 2) Warewashing Room (N, Optional) Dietary Day Storage (V, Optional) Laundry, General (V, 2) Soiled Linen Sorting and Storage (N, Optional) Area Designation (Minimum Air Changes of Outdoor Air Per Hour Supplied to Room) Patient Area Corridor (Optional) Physical Therapy (2) Occupational Therapy (2) Soiled Work Room or Soiled Holding (2) *Toilet Room (Optional) Bathroom (Optional) Janitor's Closet(s) (Optional) Linen and Trash Chute Room (Optional) Food Preparation Center (2) Warewashing Room (Optional) Dietary Day Storage (Optional) Laundry, General (2) Soiled Linen Sorting and Storage (Optional) Area Designation (Minimum Total Air Changes Per Hour Supplied to Room) Patient Area Corridor (2) Physical Therapy (4) Occupational Therapy (4) Soiled Work Room or Soiled Holding (10) *Toilet Room (6) Bathroom (6) Janitor's Closet(s) (6) Linen and Trash Chute Room (6) Food Preparation Center (6) Warewashing Room (6) Dietary Day Storage (2) Laundry, General (6) Soiled Linen Sorting and Storage (10) Area Designation (All Air Exhausted Directly to Outdoors) Patient Area Corridor (Optional) Physical Therapy (Optional) Occupational Therapy (Optional) Soiled Work Room or Soiled Holding (Yes) *Toilet Room (Yes) Bathroom (Yes) Janitor's Closet(s) (Yes) Linen and Trash Chute Room (Yes) Food Preparation Center (Yes) Warewashing Room (Yes) Dietary Day Storage (Yes) Laundry, General (Yes) Soiled Linen Sorting and Storage (Yes) Area Designation (Air Returned from This Room) Patient Area Corridor (Optional) Physical Therapy (Optional) Occupational Therapy (Optional) Soiled Work Room or Soiled Holding (No) *Toilet Room (No) Bathroom (No) Janitor's Closet(s) (No) Linen and Trash Chute Room (No) Food Preparation Center (Optional) Warewashing Room (No) Dietary Day Storage (No) Laundry, General (No) Soiled Linen Sorting and Storage (No) P = Positive N = Negative E = Equal V = Variable *Up to 75 cubic feet per minute (cfm) of make-up air for each patient room toilet may be supplied to the corridor and need not be supplied directly to the room. NOTE: In the interest of energy conservation, energy saving design innovations that are not in strict conformance with these requirements which do not adversely affect direct patient care, will be acceptable if approved in writing by the Division of Aging. 26-NOV-10Refer to definitions of Class I, I/II, II, II/III, III deficiencies
(H) All electrical appliances shall be Underwriters ' Laboratories (UL) or Factory Mutual (FM)-approved, shall be maintained in good repair, and no appliances or electrical equipment shall be used which emit fumes or which could in any other way present a hazard to the residents. I/II 26-NOV-10Refer to definitions of Class I, I/II, II, II/III, III deficiencies
(B) All facilities shall test and maintain the complete fire alarm system in accordance with NFPA 72, 1999 edition. I/II 26-NOV-10Refer to definitions of Class I, I/II, II, II/III, III deficiencies
(13) Each floor of an existing licensed facility shall have at least two (2) unobstructed exits remote from each other. One (1) of the required exits in an existing multi-story facility must be an outside stairway or an enclosed stair that is separated by one (1)-hour construction from each floor and has an exit leading directly outside at grade level. One (1) exit may lead to a lobby with exit facilities to the ground level outside instead of leading directly to the outside. The lobby shall have at least a one (1)-hour fire-rated separation from the remainder of the exiting floor. I/II 26-NOV-10Refer to definitions of Class I, I/II, II, II/III, III deficiencies
(25) Facilities shall have emergency lighting of sufficient intensity to provide for the safety of residents and other people using any exit, stairway, and corridor. The lighting shall be supplied by an emergency service, an automatic emergency generator or battery lighting system. This emergency lighting system shall be equipped with an automatic transfer switch. In an existing licensed facility, battery lights, if used, shall be wet cell units or other rechargeable-type batteries that shall be UL-approved and capable of operating the light for at least one and one-half (1 ) hours. Battery-operated emergency lighting shall be tested for at least thirty (30) seconds every thirty (30) days, and an annual function test shall be conducted for the full operational duration of one and one-half (1 ) hours. Records of these tests shall be documented and maintained for review. II 26-NOV-10Refer to definitions of Class I, I/II, II, II/III, III deficiencies