HospitalInspections.org

Based upon observations and staff interviews on June 15, 2021 between approximately 0815 hours and 1715 hours and June 16, 2021 between approximately 0700 hours and 1430 hours the facility has failed to maintain the facility in accordance with NFPA 101 (2012) 19.1. Failure to maintain in accordance with 2012 NFPA 101 may place patients, staff, and visitors at a greater risk of exposure to toxic gases.

The findings include:

Carbon monoxide detection was not provided in the following locations:
General Surgery (Chestnut Street Suite A) Building
Orthopedic Surgery (Chestnut Street Suite D) Building
Home Health & Hospice (Radio Road)
Workplace Health (Mountain View)
Occupational Therapy (Mountain View)
Physical Therapy (Mountain View)
Urgent Care (Cle Elum)

NFPA 101 19.1.1.1.3 General. The provisions of Chapter 4, General, shall apply.

NFPA 101 4.6.1.2 Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

IFC 1103.9 Carbon monoxide alarms. Existing Group I or Group R occupancies shall be provided with single station carbon monoxide alarms in accordance with Section 915.4.3. An inspection will occur when alterations, repairs or additions requiring a permit occur, or when one or more sleeping rooms are added or created. The carbon monoxide alarms shall be listed as complying with UL 2034 and be installed and maintained in accordance with NFPA 720-2015 and the manufacturer's instructions.
EXCEPTIONS:
1. For other than R-2 occupancies, if the building does not contain a fuel-burning appliance, a fuel-burning fireplace, or an attached garage.
2. Work involving the exterior surfaces of dwellings, such as the replacement of roofing or siding, or the addition or replacement of windows or doors, or the addition of a porch or deck, or electrical permits.
3. Installation, alteration or repairs of non-combustion plumbing or mechanical systems.
4. Sleeping units or dwelling units in I and R-1 occupancies and R-2 college dormitories, hotel, DOC prisons and work releases and assisted living facilities and residential treatment facilities licensed by the state of Washington which do not themselves contain a fuel-burning appliance, a fuel-burning fireplace, or have an attached garage, need not be provided with carbon monoxide alarms provided that:
4.1. The sleeping units or dwelling unit is not adjacent to any room which contains a fuel-burning appliance, a fuel-burning fireplace, or an attached garage; and
4.2. The sleeping units or dwelling unit is not connected by duct work or ventilation shafts with a supply or return register in the same room to any room containing a fuel-burning appliance, a fuel-burning fireplace, or to an attached garage; and
4.3. The building is provided with a common area carbon monoxide detection system.
5. An open parking garage, as defined in the International Building Code, or enclosed parking garage ventilated in accordance with Section 404 of the International Mechanical Code shall not be considered an attached garage.

The above was discussed and acknowledged by the Chief Executive Officer and the Chief of Facilities.

Based upon observations and staff interviews on June 15, 2021 between approximately 0815 hours and 1715 hours and June 16, 2021 between approximately 0700 hours and 1430 hours the facility has failed to maintain fire resistive construction of the building capable of resisting the passage of smoke and fire into other compartments. This could allow the toxic product of combustion to move out of a room and into the exit access corridor and the smoke compartment which would endanger the patients, staff and/or visitors within the facility.

The findings include:

Hospital - Generator room - portions of the fire stop system previously in place have been removed.

NFPA 101 8.3.5 Penetrations. The provisions of 8.3.5 shall govern the materials and methods of construction used to protect through-penetrations and membrane penetrations in fire walls, fire barrier walls, and fire resistance-rated horizontal assemblies. The provisions of 8.3.5 shall not apply to approved existing materials and methods of construction used to protect existing through-penetrations and existing membrane penetrations in fire walls, fire barrier walls, or fire resistance-rated horizontal assemblies, unless otherwise required by Chapters 11 through 43.
8.3.5.1 Firestop Systems and Devices Required. Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. The firestop system or device shall be tested in accordance with ASTM E 814, Standard Test Method for Fire Tests of Through Penetration Fire Stops, or ANSI/UL 1479, Standard for Fire Tests of Through-Penetration Firestops, at a minimum positive pressure differential of 0.01 in. water column (2.5 N/m2) between the exposed and the unexposed surface of the test assembly.

The above was discussed and acknowledged by the Chief Executive Officer and the Chief of Facilities.

Based upon observations and staff interviews on June 15, 2021 between approximately 0815 hours and 1715 hours and June 16, 2021 between approximately 0700 hours and 1430 hours the facility has failed to maintain the ability of doors to be held open only by devices arranged to automatically close upon activation of the fire alarm. This could result in the passage of smoke or fire from one compartment into another compartment thereby exposing patients, staff, and/or visitors to the toxic products of combustion.

The findings include:

Hospital - Fire door 10293366 blocked open.
Urgent Care (Cle Elum) - Lab/Soiled linen room was blocked open.
Occupational Therapy (Mountain View) - Doors with self-closers are blocked open.
Physical Therapy (Mountain View) - Staff room door was blocked open with door stop. Corrected during inspection.

NFPA 101 7.2.1.8.1 A door leaf normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2, unless otherwise permitted by 7.2.1.8.3.
7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, door leaves shall be permitted to be automatic-closing, provided that all of the following criteria are met:
(1) Upon release of the hold-open mechanism, the leaf becomes self-closing.
(2) The release device is designed so that the leaf instantly releases manually and, upon release, becomes self-closing, or the leaf can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door leaf release service in NFPA 72, National
Fire Alarm and Signaling Code.
(4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door leaf becomes self-closing.
(5) The release by means of smoke detection of one door leaf in a stair enclosure results in closing all door leaves serving that stair.
7.2.1.8.3 The elevator car doors, and the associated hoistway enclosure doors, at the floor level designated for recall in accordance with the requirements of 9.4.3 shall be permitted to remain open during Phase I Emergency Recall Operation.


Hospital - Fire Door 10268102 one leaf does not latch when closed.
Hospital - Fire Door 10269660 one leaf does not latch when closed. Corrected during inspection.
Hospital - Preoperative Clean Utility - door does not close and latch.
Home Health & Hospice (Radio Road) - a leaf on each cross corridor doors by accounting office and by the front office do not latch when closed.
Urgent Care (Cle Elum) - Clean utility room door did not have enough closing force to latch when closed.
Physical Therapy (Mountain View) - Storage room door did not have enough closing force to latch when closed.



The above was discussed and acknowledged by the Chief Executive Officer and the Chief of Facilities.

Based upon observations and staff interviews on June 15, 2021 between approximately 0815 hours and 1715 hours and June 16, 2021 between approximately 0700 hours and 1430 hours the facility has failed to maintain emergency power for the illumination of the means of egress so that in the event of a power failure the means of egress will remain illuminated. This could result in tripping and fall injuries and/or delay in evacuation of patients, staff, and/or visitors.

The findings include:

General Surgery (Chestnut Street Suite A) - Emergency sign and exit sign's test button is broken preventing the ability to test.

NFPA 101 7.10.9.2 Testing. Exit signs connected to, or provided with, a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.
7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).

The above was discussed and acknowledged by the Chief Executive Officer and the Chief of Facilities.

Based upon observations and staff interviews on June 15, 2021 between approximately 0815 hours and 1715 hours and June 16, 2021 between approximately 0700 hours and 1430 hours the facility has failed to maintain records of testing for the emergency battery backup lighting. This could result in the failure of the battery powered backup lighting in the event of a power outage and render the means of egress dark. This could result delayed egress and in tripping and fall injuries to patients, staff, and/or visitors.

The findings include:

Emergency lighting in the following locations did not have an annual 90 minute power test performed:
General Surgery (Chestnut Street Suite A) Building
Orthopedic Surgery (Chestnut Street Suite D) Building
Home Health & Hospice (Radio Road)
Workplace Health (Mountain View)
Occupational Therapy (Mountain View)
Physical Therapy (Mountain View)
Urgent Care (Cle Elum)

NFPA 101 7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.

The above was discussed and acknowledged by the Chief Executive Officer and the Chief of Facilities.

Based upon observations and staff interviews on June 15, 2021 between approximately 0815 hours and 1715 hours and June 16, 2021 between approximately 0700 hours and 1430 hours the facility has failed to maintain proper exit signage. This could potentially misdirect patients, staff, and/or visitors during an emergency.

The findings include:

Exit signs in the following locations did not have an annual 90 minute power test performed:
General Surgery (Chestnut Street Suite A) Building
Orthopedic Surgery (Chestnut Street Suite D) Building
Home Health & Hospice (Radio Road)
Workplace Health (Mountain View)
Occupational Therapy (Mountain View)
Physical Therapy (Mountain View)
Urgent Care (Cle Elum)

NFPA 101 7.10.9.2 Testing. Exit signs connected to, or provided with, a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.
7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.

The above was discussed and acknowledged by the Chief Executive Officer and the Chief of Facilities.

Based upon record review and staff interviews on June 15, 2021 between approximately 0815 hours and 1715 hours and June 16, 2021 between approximately 0700 hours and 1430 hours the facility has failed to conduct testing/maintenance of the hood and duct fire suppression equipment protecting the commercial cooking equipment. This could result in the failure of the system to operate properly which would endanger the patients, staff, and/or visitors within the facility.

The findings include:

The facility was unable to provide documentation of second semi-annual hood suppression system service in 2020.

Service contractor's reports must be free of deficiencies.

NFPA 101 9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 96 11.2 Inspection, Testing, and Maintenance of Fire-Extinguishing Systems.
11.2.1 Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at least every 6 months.

11.2.4 Fusible links of the metal alloy type and automatic sprinklers of the metal alloy type shall be replaced at least semiannually except as permitted by 11.2.6 and 11.2.7.

The above was discussed and acknowledged by the Chief Executive Officer and the Chief of Facilities.

Based on observation and staff interview on June 15, 2021 between approximately 0815 hours and 1715 hours and June 16, 2021 between approximately 0700 hours and 1430 hours the facility has failed to have appropriate testing of the fire alarm system which result in the failure to notify staff of a problem with the fire alarm system. This could lead to the system not functioning as intended and lead patients, staff, and visitors within the building not being notified of a fire.

The findings include:

Home Health & Hospice (Radio Road) - The facility was unable to provide documentation of correction to the deficiency documented on the fire alarm service report indicating a bell in the corridor outside room 34 failed when tested.

Service contractor's reports must be free of deficiencies.

NFPA 101 9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

NFPA 72 14.2.1.2.2 System defects and malfunctions shall be corrected.


Home Health & Hospice (Radio Road) - The facility was unable to provide documentation of smoke detector sensitivity testing within the past five years.

Service contractor's reports must be free of deficiencies.

14.4.5.3.3 After the second required calibration test, if sensitivity tests indicate that the device has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years.

The above was discussed and acknowledged by the Chief Executive Officer and the Chief of Facilities.

Based on observation and staff interview on June 15, 2021 between approximately 0815 hours and 1715 hours and June 16, 2021 between approximately 0700 hours and 1430 hours the facility has failed to maintain the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire and allow the fire to increase in size and intensity which would endanger the patients, staff, and/or visitors within the facility.

The findings include:

Hospital - Preoperative Room 3 - Loaded sprinkler head.
Hospital - Endoscopy Rooms 1 & 2 - Loaded sprinkler heads.

NFPA 25 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5)Loading
(6) Painting unless painted by the sprinkler manufacturer
A.5.2.1.1.2(5) In lieu of replacing sprinklers that are loaded with a coating of dust, it is permitted to clean sprinklers with compressed air or by a vacuum provided that the equipment does not touch the sprinkler.


Home Health & Hospice (Radio Road) - The facility was unable to provide documentation of five year internal inspection of fire sprinkler system.

Home Health & Hospice (Radio Road) - The facility was unable to provide documentation of quarterly inspections of the fire sprinkler system.

Service contractor's reports must be free of deficiencies.

The above was discussed and acknowledged by the Chief Executive Officer and the Chief of Facilities.

Based on observation and staff interview on June 15, 2021 between approximately 0815 hours and 1715 hours and June 16, 2021 between approximately 0700 hours and 1430 hours the facility failed to maintain their fire extinguishers in accordance with NFPA 10. This potentially delays a quick response to contain a fire from spreading which could expose and endanger patients, staff, and/or visitors within the facility.

The findings include:

Orthopedic Surgery (Chestnut Street Suite D) - Fire extinguisher by biohazard closet last inspected on 04/25/21.
Hospital - Computerized Tomography Control Room - Halon fire extinguisher had not been inspected in May and June 2021.

NFPA 101 9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10 7.2.1.2 Fire extinguishers shall be inspected either manually or by means of an electronic monitoring device/system at a minimum of 30-day intervals.


Hospital - Operating rooms 2 & 3 - access to fire extinguishers were obstructed by equipment.
Physical Therapy (Mountain View) - access to fire extinguisher in back corridor was obstructed by a laundry cart.

NFPA 10 6.1.3.3.1 Fire extinguishers shall not be obstructed or obscured from view.


Hospital - Medical Gas Storage room - six fire extinguishers are unsecured on the floor.

NFPA 10 6.1.3.4 Portable fire extinguishers other than wheeled extinguishers shall be installed using any of the following means:
(1) Securely on a hanger intended for the extinguisher
(2) In the bracket supplied by the extinguisher manufacturer
(3) In a listed bracket approved for such purpose
(4) In cabinets or wall recesses


The above was discussed and acknowledged by the Chief Executive Officer and the Chief of Facilities.

Based on observation and staff interview on June 15, 2021 between approximately 0815 hours and 1715 hours and June 16, 2021 between approximately 0700 hours and 1430 hours the facility has failed to maintain electric and gas equipment in a safe manner and in accordance with NFPA 70. This could endanger patients, staff, and visitors in the building by risk of fire, electrocution, or other harm.

The findings include:

General Surgery (Chestnut Street Suite A) Conference Room - 2 abandoned junction boxes were not covered.
Hospital - Emergency Room 1 - two electrical cover plates were missing.
Hospital - SOP Waiting Room - loose electrical receptacle.
Hospital - Radiology Scheduling - two electrical cover plates were missing.

NFPA 101 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70 314.20 In Wall or Ceiling. In walls or ceilings with a surface of concrete, tile, gypsum, plaster, or other noncombustible material, boxes employing a flush-type cover or faceplate shall be installed so that the front edge of the box, plaster ring, extension ring, or listed extender will not be set back of the finished surface more than 6 mm (1?4 in.). In walls and ceilings constructed of wood or other combustible surface material, boxes, plaster rings, extension rings, or listed extenders shall be flush with the finished surface or project therefrom.

Electrical panels were blocked in the following locations:

Orthopedic Surgery (Chestnut Street Suite D) - by biohazard closet.
Hospital - Labor and Delivery corridor.
Hospital - Surgery Sterile Storage.
Hospital - Surgery Sterile/Dirty corridor.

NFPA 101 7.4.2 Spaces About Electrical Equipment.

7.4.2.1 600 Volts, Nominal, or Less. The minimum number of means of egress for working space about electrical equipment, other than existing electrical equipment, shall be in accordance with NFPA 70, National Electrical Code, Section 110.26(C).

7.4.2.2 Over 600 Volts, Nominal. The minimum number of means of egress for working space about electrical equipment, other than existing electrical equipment, shall be in accordance with NFPA 70, National Electrical Code, Section 110.33(A).

NFPA 70, 110.26 Spaces About Electrical Equipment. Access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment.

The above was discussed and acknowledged by the Chief Executive Officer and the Chief of Facilities.

Based on observation and staff interview on June 15, 2021 between approximately 0815 hours and 1715 hours and June 16, 2021 between approximately 0700 hours and 1430 hours the facility has failed to ensure dampers in the facility were inspected and provided necessary maintenance at least every four years in accordance with NFPA 90A. LSC 9.2.1 requires heating, ventilating and air conditioning (HVAC), ductwork and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems.

NFPA 90A, 2012 Edition, Section 5.4.8.1 states fire dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. NFPA 80, 2010 Edition, Section 19.4.1 states each damper shall be tested and inspected 1 year after installation. The test and inspection frequency shall be every 4 years. If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in-place if so equipped. The damper shall not be blocked from closure in any way. All inspections and testing shall be documented, indicating the location of the fire damper, date of inspection, name of inspector and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. This deficient practice could affect all patients, staff, and visitors.

The findings include:

Home Health and Hospice (Radio Road) - The facility was unable to provide documentation that fire/smoke dampers have been inspected and tested.

NFPA 101 8.5.5.2 Smoke Dampers. Where a smoke barrier is penetrated by a duct or air-transfer opening, a smoke damper designed and tested in accordance with the requirements of ANSI/UL 555S, Standard for Smoke Dampers, shall be installed. Where a smoke barrier is also constructed as a fire barrier, a combination fire/smoke damper designed and tested in accordance with the requirements of ANSI/UL 555, Standard for Fire Dampers, and ANSI/UL 555S, Standard for Smoke Dampers, shall be installed.
8.5.5.3 Smoke Damper Exemptions. Smoke dampers shall not be required under any of the following conditions:
(1) Where specifically exempted by provisions in Chapters 11 through 43
(2) Where ducts or air-transfer openings are part of an engineered smoke control system
(3) Where the air in ducts continues to move and the air handling system installed is arranged to prevent recirculation of exhaust or return air under fire emergency conditions
(4) Where the air inlet or outlet openings in ducts are limited to a single smoke compartment
(5) Where ducts penetrate floors that serve as smoke barriers
(6) Where ducts penetrate smoke barriers forming a communicating space separation in accordance with 8.6.6(4)(a).

Hospital - The facility was unable to provide documentation of repairs and maintenance of items found on annual fire door inspection.

Service contractor's reports must be free of deficiencies.

NFPA 101 8.5.5.4.2 Smoke dampers and combination fire and smoke dampers required by this Code shall be inspected, tested, and maintained in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives.

NFPA 105 6.5.11 All inspections and testing shall be documented indicating the location of the damper, date of inspection, name of inspector, and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected.
6.5.12 All documentation shall be maintained by the property owner and available for review by the authority having jurisdiction.

The above was discussed and acknowledged by the Chief Executive Officer and the Chief of Facilities.

Based on observation and staff interview on June 15, 2021 between approximately 0815 hours and 1715 hours and June 16, 2021 between approximately 0700 hours and 1430 hours the facility failed to properly maintain all building service equipment. Failure to maintain building service equipment exposes patients, staff, and visitors to a greater risk of heat, fire, and smoke.

The findings include:

The facility was unable to provide documentation of monthly firefighter recall testing.

NFPA 101 9.4.6.2 All elevators equipped with fire fighters' emergency operations in accordance with 9.4.3 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME A17.1/CSA B44, Safety Code for Elevators and Escalators.

9.4.3.2 All existing elevators having a travel distance of 25 ft (7620 mm) or more above or below the level that best serves the needs of emergency personnel for fire-fighting or rescue purposes shall conform to the fire fighters' emergency operations requirements of ASME A17.3, Safety Code for Existing Elevators and Escalators.

The above was discussed and acknowledged by the Chief Executive Officer and the Chief of Facilities.

Based on observation and staff interview on June 15, 2021 between approximately 0815 hours and 1715 hours and June 16, 2021 between approximately 0700 hours and 1430 hours the facility has failed to provide fire drill records reflecting drills being conducted on all shifts for each quarter for the past 12 months. This could potentially result in the staff not responding in a coordinated manner in the event of a fire or other emergency and endangering patients, staff, and/or visitors.

The findings include:

The facility was unable to provide documentation of fire drills at the following locations:

General Surgery (Chestnut Street Suite A) Building - no documentation available for the past calendar year.
Orthopedic Surgery (Chestnut Street Suite D) Building - no documentation available for the past calendar year.
Occupational Therapy (Mountain View) - no documentation available for the calendar year.
Physical Therapy (Mountain View) - no documentation available for the past year.
Urgent Care (Cle Elum) - only documented drill provided within the past year was 02/02/21 and 02/09/21.

19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

The above was discussed and acknowledged by the Chief Executive Officer and the Chief of Facilities.

Based upon observations and staff interviews on June 15, 2021 between approximately 0815 hours and 1715 hours and June 16, 2021 between approximately 0700 hours and 1430 hours the facility has failed to test all fire rated doors in accordance with NFPA 80. This could lead to the doors not functioning as required in a fire, endangering patients, visitors, and staff inside the building.

The findings include:

The facility was unable to provide documentation reflecting all doors on annual inspection and status reports have all repairs/corrections completed.

Service contractor's reports must be free of deficiencies.

NFPA 80 5.2.15 Repair of Fire Doors and Windows.
5.2.15.1 Damaged glazing material shall be replaced with labeled glazing.
5.2.15.1.1 Replacement glazing materials shall be installed in accordance with their individual listing.
5.2.15.2 Any breaks in the face covering of doors shall be repaired immediately.
5.2.15.3 Where a fire door, frame, or any part of its appurtenances is damaged to the extent that it could impair the door's proper emergency function, the following actions shall be performed:
(1) The fire door, frame, door assembly, or any part of its appurtenances shall be repaired with labeled parts or parts obtained from the original manufacturer.
(2) The door shall be tested to ensure emergency operation and closing upon completion of the repairs.
5.2.15.3.1 If repairs cannot be made with labeled components or parts obtained from the original manufacturer or retrofitted in accordance with Section 5.3, the fire door frame, fire door assembly, or appurtenances shall be replaced.
5.2.15.4 When holes are left in a door or frame due to changes or removal of hardware or plant-ons, the holes shall be repaired by the following methods:
(1) Install steel fasteners that completely fill the holes
(2) Fill the screw or bolt holes with the same material as the door or frame

The above was discussed and acknowledged by the Chief Executive Officer and the Chief of Facilities.

Based on observation and staff interview on June 15, 2021 between approximately 0815 hours and 1715 hours and June 16, 2021 between approximately 0700 hours and 1430 hours the facility failed to maintain their medical gas equipment through testing and inspection possible leading to a problem not being detected, and thus place patients, staff, and visitors to the threat of an accelerated fire or a non-functioning system.

The findings include:

Hospital - The facility was unable to provide documentation reflecting the medical gas and vacuum systems deficiencies noted on the inspection/testing and the status reports have all the corrections completed

Service contractor's reports must be free of deficiencies.

NFPA 99 5.1.12.1.8 The responsible facility authority shall review these inspection and testing records prior to the use of all systems to ensure that all findings and results of the inspection and testing have been successfully completed.

The above was discussed and acknowledged by the Chief Executive Officer and the Chief of Facilities.

Based on observation and staff interview on June 15, 2021 between approximately 0815 hours and 1715 hours and June 16, 2021 between approximately 0700 hours and 1430 hours the facility failed to restrict the use of extension cords and non-approved power strips in their facility. This could endanger patients, staff, and visitors in the facility due to the increased fire risk.

The findings include:

General Surgery (Chestnut Street Suite A) Conference Room - Extension course in use.

Hospital - Medical Surgical Department Discharge Planner & Social Services office - frayed cord.

Home Health and Hospice (Radio Road) - Front office under desk - Cord hanging in a manner that causes tension on electrical cord.

NFPA 70 400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B)
(5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
(6) Where installed in raceways, except as otherwise permitted in this Code
(7) Where subject to physical damage






Multiplug adapters were plugged into other Multiplug adapters in the following locations:
Hospital - Information Systems Support Services - two locations.
Hospital - Grant Writer's office - behind desk.
Hospital - Emergency Department Chart Room.
Hospital - Emergency Department West Nurses Station - under desk.
Hospital - Materials management front office - under desks.
Home Health & Hospice (Radio Road) - Billing Denial Room - under desk on left side of the room.
Occupational Therapy (Mountain View) - Information Technology Network Administrator's office.
Occupational Therapy (Mountain View) - Information Technology Chief Information Officer's office.

NFPA 101 2.4 References for Extracts in Mandatory Sections.
NFPA 1, Fire Code, 2012 edition.

NFPA 1 11.1.6.2 The relocatable power taps shall be directly connected to a permanently installed receptacle.

The above was discussed and acknowledged by the Chief Executive Officer and the Chief of Facilities.

Based on observation and staff interview on June 15, 2021 between approximately 0815 hours and 1715 hours and June 16, 2021 between approximately 0700 hours and 1430 hours the facility has failed to maintain separation of oxygen cylinders. This could allow for using an empty cylinders in a medical emergency, which could endanger patients, staff, and/or visitors.

The findings include:

Urgent Care (Cle Elum) - empty and full oxygen cylinders were not segregated.

NFPA 99, 11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders.

The above was discussed and acknowledged by the Chief Executive Officer and the Chief of Facilities.