Other·August 27, 2021

F921 §483.90(i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Title 22 Division 5 Chapter 3 Article 6 § 72601. Alterations to Existing Buildings or New Construction. (a) Alterations to existing buildings licensed as skilled nursing facilities or new construction shall be in conformance with Chapter I, Division 17. Part 6. Title 24, California Administrative Code and requirements of the State Fire Marshal. (c) All facilities shall maintain in operating condition all buildings, fixtures and spaces in the numbers and types as specified in the construction requirements under which the facility or unit was first licensed. § 72605. Notice to Department. The Department shall be notified in writing, by the owner or licensee of the skilled nursing facility, within five days of the commencement of any construction, remodeling, or alterations to such facility. On 6/10/2021, an unannounced visit was conducted to investigate a facility a facility reported incident regarding physical environment. The facility failed to: 1. Maintain one laundry dryer machine free from lint buildup. 2. Failed to maintain the door of the laundry room in good operating condition to allow the door to positively latch for one smoke compartment. Hazardous areas include rooms or spaces larger than 50 square feet used for storage of combustible supplies and equipment and central laundries greater than 100 square feet. In the event of a fire, containment of smoke and fire would not be achieved with non-latching doors in hazardous areas. 3. Failed to acquire required building permits and obtain construction approval from the authority having jurisdiction - Office of Statewide Health Planning & Development (OSHPD is the State agency that reviews and approved plans for construction, repairs, renovations, and remodeling made to buildings to comply with State codes) prior to alterations in the existing laundry room. As a result, on 6/9/2021 at 7:11 p.m., there was ignition (starting to burn) of the lint, production, and release of smoke placing the total census of 35 residents at risk for burns or smoke inhalation, had the fire spread throughout the facility. 1. On 6/10/2021, at 12:41 p.m., during an interview, Laundry Aide 1 (LA 1) stated that on 6/9/2021 at 7:11 p.m., she heard the fire alarm while walking on the hallway of the facility. LA 1 opened the door to the laundry room to investigate and saw smoke inside. She pulled the closest manual pull alarm and informed the charge nurse of the smoke. LA 1 explained that the dryers and washers were in use at the time. During an interview on 6/10/2021, at 1:40 p.m., Licensed Vocational Nurse 2 (LVN 2) stated she went to investigate the source of the smoke, entered the laundry room, observed black smoke coming from a dryer, and used the portable fire extinguisher to extinguish the smoke from the dryer. During interviews on 6/10/2021, at 2 p.m., with the Director of Nursing (DON) and the Maintenance Supervisor (MS), the MS stated he received a phone call from the Administrator (ADM) informing him of the incident, and when he arrived at the facility on 6/9/2021, at 7:45 p.m., he observed the dryer was removed from the laundry room and placed outside the facility. The DON added, it was the Fire Department (firefighters) removed the dryer from the laundry room. During an observation on 6/10/2021, at 2:23 p.m., with the DON and MS, the corridor to the laundry room was tested for automatically closing and latching. The corridor door to the laundry room did not automatically latch when closed. The DON stated that the door did not automatically latch only two times when tested. During a concurrent observation and interview on 6/10/2021, at 2:28 p.m., with the DON and MS, the door between the clean linen room and the washing and drying room was open. The MS confirmed the observation and stated laundry staff closes the door when handling soiled linen in the washing and drying area. The laundry room door to the exterior was also left open. There was unfinished exterior wall construction outside the laundry room. During an interview on 6/10/2021, at 2:33 p.m., the MS stated the exterior door to the laundry room was left open to help ventilate the laundry room. During an interview with the ADM on 6/10/2021, at 2:35 p.m., the ADM stated there were on-going OSHPD projects for the laundry room and the boiler/water heater. The ADM explained there was non-permitted addition to the existing laundry room that had been removed. During a concurrent interview and observation with the ADM on 6/10/2021, at 2:38 p.m., the ADM there was accumulation of lint on the ground below the dryer machine exhaust vent behind the laundry room. During a concurrent observation and interview on 6/10/2021, at 2:44 p.m., with the ADM, DON, and MS, the corridor door to the laundry room for automatically closing and latching was re-tested. The corridor door to the linen room did not automatically latch when closed five out of five times. The ADM stated that about one week ago, there were issues with the door slamming and maintenance staff adjusted the self-closing device and may have tightened the screw which prevented it from latching. During an interview with the DON on 6/10/2021, at 4:19 p.m., the DON stated the MS measured the size of the laundry room and the approximate size was 230 square feet. A review of the facility's policy and procedures titled, "Fire and Smoke Barrier Doors" revised on 4/2008, the policy indicated, "Fire and smoke barrier doors are strategically located throughout the facility and such doors remain operable at all times." The document also indicated that staff shall report fire and smoke doors that do not close properly in writing to the Maintenance Supervisor and notify the Safety Coordinator. A review of the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 Edition, Chapter 19, Existing Healthcare Occupancy, the Code indicated that hazardous areas shall have self-closing or automatic-closing doors. Hazardous areas shall include central/bulk laundries larger than 100 square feet and rooms or spaces larger than 50 square feet used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction. 2. During an observation on 6/10/2021, at 3:02 p.m., with the ADM and Maintenance Staff 1 (MS 1), the MS 1 brought out the dryer to the front lawn of the facility to be examined. There was blackened burnt lint on the bottom interior of the dryer cabinet. During a concurrent interview, MS 1 stated the dryer was designed with spaces that allowed lint to flow through and accumulate on the non-serviceable (not easily reached) area. MS 1 explained lint above the burner housing could have easily ignited and was pulled into the tub/drum of the dryer. MS 1 added, it possibly happened towards the end of the cycle. MS 1 also stated the bottom interior of the dryer cabinet was not serviced by the facility staff and that the facility "might need to implement something." During an interview on 6/11/2021, at 12:15 p.m., the MS stated the monthly deep cleaning of dryer includes taking off the lid, taking off parts, and cleaning of interior with a vacuum. The MS added that he cleans what he could. During an interview with the ADM on 6/11/2021, at 12:59 p.m., the ADM stated that the dryer had been in use since 12/2019. The ADM also stated she had seen technician clean the inside of the dyers and washers during repairs. The ADM stated the facility replaces the washer and dryers often. During an interview with the ADM on 6/11/2021, at 12:23 p.m., the ADM stated all laundry was done in-house, about 32 loads a day, and with two dryers in use, it would be 16 loads per dryer, per day. ADM also stated laundry staff shifts starts at 6:30 a.m. and ends at 10 or 11 p.m. On 6/11/2021, at 12:59 p.m., during an interview, the ADM confirmed not notifying OSHPD to obtain approval/authorization when replacing washers and dryers in the laundry room. A review of the facility's policy and procedures titled, "Washer and Dryer Maintenance" revised on 4/15/2017, the policy indicated, "Dryers will be deep cleaned/inspected monthly, taking sides off to ensure no buildup of lint has occurred on mechanisms inside the dryer." A review of the dryer manufacturer's use and care guide (undated) indicated removal of accumulated lint from inside of the dryer cabinet every two years, or more often, depending on the dryer usage. The document also indicated that cleaning should be done by a qualified servicer. A review of OSHPD’s Fire and Life and Safety Report and Construction Advisory Report, dated 6/21/2021, indicated there were unauthorized construction, addition, or alteration work conducted in rooms/areas at the Northeast portion of the facility without reviews, permits, or approvals from OSHPD. The unauthorized projects included: - Alteration of existing laundry room resulting in lack of Heating, Ventilation, and Air Conditioning (HVAC) supply or return/exhaust, combustion air for the gas appliance. - Installation of newer clothes dryer exhaust vents in laundry room. - Installation of two clothes washers and sewer waste piping, missing the appropriate trap seal for the appliances. 3. During an interview with the OSHPD’s Fire Marshal on 8/2/2021, at 12:28 p.m., the Fire Marshal explained that if there was an excessive build-up of lint on the gas clothes dryer appliance, the exhaust discharge could have been blocked allowing the lint to accumulate and create a greater hazard. Having no HVAC supply or return/exhaust in the existing laundry room adds to the concern since adequate outside air was not being provided for combustion air for the fuel burning appliance. This may have contributed to the fire since it does not appear that the appliance was operating efficiently at the time. Upon further investigation on 8/4/2021 with the ADM and DON, at 12:27 p.m., observed laundry room without HVAC supply or return/exhaust ventilation. During a concurrent interview, the DON confirmed the laundry room as the “existing” laundry room noted on the OSHPD report. The facility failed to: 1. Maintain one laundry dryer machine free from lint buildup. 2. Failed to maintain the door of the laundry room in good operating condition to allow the door to positively latch for one smoke compartment. Hazardous areas include rooms or spaces larger than 50 square feet used for storage of combustible supplies and equipment and central laundries greater than 100 square feet. In the event of a fire, containment of smoke and fire would not be achieved with non-latching doors in hazardous areas. 3. Failed to acquire required building permits and obtain construction approval from the authority having jurisdiction - Office of Statewide Health Planning & Development (OSHPD is the State agency that reviews and approved plans for construction, repairs, renovations, and remodeling made to buildings to comply with State codes) prior to alterations in the existing laundry room. As a result, on 6/9/2021 at 7:11 p.m., there was ignition (starting to burn) of the lint, production, and release of smoke placing the total census of 35 residents at risk for burns or smoke inhalation, had the fire spread throughout the facility. The facility failed to: The above violations jointly or separately had a direct or immediate relationship to the health, safety, or security of all the residents in the facility.