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Based on observation and interview, the facility failed to ensure that doors with self-closing devices were not obstructed from automatically closing.

Findings Include:

On 1/8/18 through 1/11/18, during the tour of the facility observation revealed the following doors were constructed with self-closing devices, which were held open with objects that prevented the doors to operate as designed:
1) A door in the Employee Lounge had a door chalk or wedge.
2) Door D0104 had a door chalk or wedge.
3) Storage door in the Central Sterile Services had a door chalk or wedge.
4) The EKG Room had an alcohol dispenser in front of the door.
5) Door J1722 had a door chalk or wedge.
6) Door K1754 had a trash can in front of the door.
7) Door to the gift shop office had a door chalk or wedge.

The Director of Facilities acknowledged the deficiencies at the time of discovery and during the exit interview.

Based on documentation review and interview, the facility failed to provide evidence of flame spread ratings for interior walls and ceiling finishes.

Findings include:

On 1/8/18 at approximately 10:30 AM, document review revealed no evidence of flame spread rating information as related to the interior walls and ceiling finishes.

On 1/8/18 at approximately 10:30 AM, the Director of Facilities reported there was no detailed information available to confirm the flame spread ratings for interior walls and ceiling finishes.

Based on document review and interview, the facility failed to include in their fire alarm fire watch policy, notifications to all authorities having jurisdiction.

Findings include:

On 1/8/18 at approximately 9:50 AM, document review revealed the facility failed to include the Bureau of Health Care Quality and Compliance (BHCQC), as an authority having jurisdiction that required notification if the facility initiated a fire watch.

On 1/8/18 at approximately 9:50 AM, the Director of Facilities acknowledged that BHCQC had not been included in the fire alarm fire watch policy.

NFPA 13
National Fire Protection Association (NFPA) 13, Standard for the Installation of Sprinkler Systems, 2010 Edition

6.2.6.2* Painting.
6.2.6.2.1 Sprinklers shall only be painted by the sprinkler manufacturer.
6.2.6.2.2 Where sprinklers have had paint applied by other than the sprinkler manufacturer, they shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.

6.2.7 Escutcheons and Cover Plates.
6.2.7.1 Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler.
6.2.7.2* Escutcheons used with recessed, flush-type, or concealed sprinklers shall be part of a listed sprinkler assembly.
6.2.7.3 Cover plates used with concealed sprinklers shall be part of the listed sprinkler assembly.
6.2.8 Guards. Sprinklers subject to mechanical injury shall be protected with listed guards.

6.2.9.7 A list of the sprinklers installed in the property shall be posted in the sprinkler cabinet.
6.2.9.7.1* The list shall include the following:
(1) Sprinkler Identification Number (SIN) if equipped; or the manufacturer, model, orifice, deflector type, thermal sensitivity, and pressure rating
(2) General description
(3) Quantity of each type to be contained in the cabinet
(4) Issue or revision date of the list

8.5.5 Obstructions to Sprinkler Discharge.
8.5.5.2* Obstructions to Sprinkler Discharge Pattern Development.
8.5.5.2.1 Continuous or non-continuous obstructions less than or equal to 18 inches below the sprinkler deflector that prevent the pattern from fully developing shall comply with 8.5.5.2.

8.5.6* Clearance to Storage.
8.5.6.1* Unless requirements of 8.5.6.2, 8.5.6.3, 8.5.6.4, or 8.5.6.5 are met, the clearance between the deflector and the top of storage shall be 18 inches or greater.

8.6.4.1 Distance Below Ceilings.
8.6.4.1.1 Unobstructed Construction.
8.6.4.1.1.1 Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 inches and a maximum of 12 inches throughout the area of coverage of the sprinkler.

26.1* General
A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained by the property owner or their authorized representative in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed.

NFPA 25
National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition

5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).
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
5.2.1.1.3* Any sprinkler that has been installed in the incorrect orientation shall be replaced.
5.2.1.1.4 Any sprinkler shall be replaced that has signs of leakage; is painted, other than by the sprinkler manufacturer, corroded, damaged, or loaded; or is in the improper orientation.
5.2.1.1.5 Glass bulb sprinklers shall be replaced if the bulbs have emptied.

5.3.2* Gauges.
5.3.2.1 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge.
5.3.2.2 Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

Based on observation, document review and interview, the facility failed to maintain the automatic fire sprinkler system as required.

Findings include:

1) On 1/8/18 through 1/11/18, during the tour of the facility more than 256 sprinkler heads were loaded with foreign material (dust, dirt, grease, rust, corrosion). The discovery of loaded sprinkler heads was a systemic issue found throughout every portion of the facility.

2) On 1/8/18 through 1/11/18, a tour of the building revealed all fire sprinkler gauges were dated from 2009. There was no evidence the gauges had been tested or changed after 2009.

3) On 1/8/18 at appropriately 1:30 PM, observation of the main fire sprinkler riser room revealed the fire sprinkler spare boxes did not have a list of sprinklers installed in the property and did not list the quantity of each type of sprinkler to be contained in the spare cabinet.

4) On 1/8/18 through 1/11/18, a tour of the building revealed 42 sprinklers were missing their escutcheons or their escutcheons had been painted and/or caulked to the ceiling.

5) On 1/9/18 at approximately 1:15 PM, a tour of the Emergency Department revealed a sprinkler deflector in the hall outside of treatment area #4 was between 1/2 and 3/4 inches from the ceiling.

6) On 1/10/18 at approximately 9:45 AM, observation in Stairwell 5 of the East entrance revealed a sprinkler deflector was 1/4 inch from the ceiling.

7) On 1/8/18 through 1/11/18, the interstitial space was observed (above the tiled ceiling or hard lid ceiling), at 15 locations interspersed throughout all levels of the facility. At each of the 15 locations wires, conduit and/or duct work insulation were observed to be resting on or against sprinkler pipes.

8) On 1/10/18 at approximately 2:20 PM, observation of the Valley View Room (3rd floor), revealed three sprinklers with clear frangible bulbs. All other sprinklers installed in this room had frangible bulbs that were red.

9) On 1/10/18 at approximately 9:05 AM, observation of the Quality Department (QD) revealed that fire sprinkler coverage was not complete in the hallway serving the QD offices. Observation of the hallway servicing the QD offices revealed the hallway was 58' long. There were two fire sprinklers located in the hallway near rooms E1411 and E1410 (east end of the hallway). There were no fire sprinklers providing coverage for the west end of the hallway near rooms E1408 and E1407.

10) On 1/8/18 through 1/11/18, observation of the sprinkler in room D0108 (Gift Shop storage) revealed plastic bins were stored 10 inches from the deflector. In room A3057, boxes were stored 16 inches from the deflector. In room N1835 (main entrance storage room) a bag of blankets was discovered to be within 13 inches of a sprinkler deflector.

11) On 1/9/18 at approximately 1:50 PM, observation of the Emergency Storage Room located under the ambulance entrance overhang revealed a bicycle was resting against and blocking the fire sprinkler riser. The riser was observed to have an active water leak below the right outlet shutoff valve.

12) On 1/10/18 between 3:10 PM and 4:15 PM, a tour of the operating rooms and clean core area on the second floor revealed two concealed sprinkler cover plates were missing. One cover plate was missing within the clean core and the other was missing in operating room #1. The missing cover plates could have exposed the areas below the sprinklers to foreign material (contaminates) dropping from the ceilings interstitial space.

13) On 1/9/18 at approximately 2:00 PM, observation of the ambulatory entrance vestibule to the Emergency Department revealed a sidewall sprinkler deflector that was less than 1/4 inch from the wall.

The Director of Facilities and Supervisor of Facilities acknowledged the deficiencies at the time of discovery and at the exit interview.



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14) During a tour of the Sierra Surgery offsite location of the hospital on 1/10/18, the sprinkler in the communications room was missing an escutcheon ring.

The offsite location facilities manager acknowledged the finding.

Based on document review and interview, the facility failed to include in their fire sprinkler fire watch policy, notifications to all authorities having jurisdiction.

Findings include:

On 1/8/18 at approximately 9:50 AM, document review revealed the facility failed to include the Bureau of Health Care Quality and Compliance (BHCQC), as an authority having jurisdiction that required notification if the facility initiated a fire watch.

On 1/8/18 at approximately 9:50 AM, the Director of Facilities acknowledged that BHCQC had not been included in the fire sprinkler fire watch policy.

National Fire Protection Association (NFPA) 10, Standard for Portable Fire Extinguishers, 2010 Edition.

6.1.3.3 Visual Obstructions.
6.1.3.3.1 Fire extinguishers shall not be obstructed or obscured from view.
6.1.3.3.2* In large rooms and in certain locations where visual obstructions cannot be completely avoided, means shall be provided to indicate the extinguisher location.
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
6.1.3.5 Wheeled fire extinguishers shall be located in designated locations.
6.1.3.6 Fire extinguishers installed under conditions where they are subject to dislodgement shall be installed in manufacturer's strap-type brackets specifically designed for this problem.
6.1.3.7 Fire extinguishers installed under conditions where they are subject to physical damage (e.g., from impact, vibration, the environment) shall be protected against damage.
6.1.3.8 Installation Height.
6.1.3.8.1 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor.
6.1.3.8.2 Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be installed so that the top of the fire extinguisher is not more than 31.2 ft
(1.07 m) above the floor.
6.1.3.8.3 In no case shall the clearance between the bottom of the hand portable fire extinguisher and the floor be less than 4 in. (102 mm).

Based on observation, the facility failed to install and maintain fire extinguishers as required by National Fire Protection Association (NFPA) 10, Standard for Portable Fire Extinguishers, 2010 Edition.

Findings include:

1) On 1/8/18 through 1/11/18, observation and measurement of fire extinguisher heights throughout the facility revealed 21 fire extinguishers ranging in height from 60.5 inches to 62 inches as measured from the finished floor. Measurements were taken by measuring from the finished floor to the top of the fire extinguisher handle.

2) On 1/10/18 at approximately 9:40 AM, observation of the fire extinguisher located in the scrub area near the vascular lab control room (room E1462) revealed the extinguisher was blocked by a biohazard bag cart.

3) On 1/11/18 at approximately 9:00 AM, observation of the fire extinguisher located in the family waiting area across from patient room A365, revealed the extinguisher was blocked by chairs.

4) On 1/8/18 through 1/11/18, observation of fire extinguisher placement and storage revealed that extinguishers throughout the building were visually obstructed or obscured. There were no visible signs identifying extinguisher locations in hallways and other locations.

The Director of Facilities and/or the Supervisor of Facilities acknowledged the deficiencies at the time of discovery.

Based on observation and interview, the facility failed to ensure walls in the EMS storage room at the offsite location of Sierra Surgery Center prevented the passage of smoke.

Findings include:

On 1/10/18, a tour of the offsite location, Sierra Surgery Center, revealed unsealed penetrations through the walls of the EMS storage room. Several conduit lines and sprinkler pipes that passed through the walls were not properly sealed to prevent the passage of smoke.

The offsite facilities manager of the Carson Tahoe Surgery center acknowledged the findings on 1/10/18.

Based on observation and interview, the facility failed to ensure smoke barrier construction was properly sealed at points of penetration.

Findings include:

On 1/8/18 through 1/11/18, observation of the following areas revealed penetrations in the smoke barrier construction:

Ground Level
1) Room A0007 - Elevator Equipment Room - three rigid conduit runs were not sealed.
2) Maintenance Storage Room - two penetrations on the hallway side of the room were not sealed.

First Floor
3) Electrical Room near Emergency Department - one conduit penetration was not sealed.
4) Interstitial Space in hall by Elevator #5 - two penetrations (1 wire and one copper pipe) not sealed.
5) Interstitial Space in hall by Room J1730 - two penetrations not sealed.
6) Interstitial Space in lobby near Room K1751 - flexible conduit run not sealed.
7) Interstitial Space in hall near Room K1771 - thee flexible conduit runs not sealed.
8) Interstitial Space in hall outside Physicians Dining Room - chilled water pipes were not completely sealed.

Second Floor
9) Interstitial Space in hall near Stairwell #3 - penetrations near four conduit runs were not sealed.
10) Interstitial Space in hall near Room G2379 - 3 inch by 3 inch hole in drywall with three red wires not sealed and one conduit run not sealed.

Third Floor
11) Interstitial Space in hall near Room C3138 - 3 inch round hole by a penetration sleeve was not sealed.
12) Interstitial Space in hall Room A370 - two red cables penetrated wall and were not sealed.
13) Interstitial Space in hall near Stairwell #6 - conduit runs were not sealed around wall or at ends of conduit. Duct work not sealed at wall.

The Director of Facilities acknowledged each deficiency at the time of discovery.

NOTE: The interstitial space was observed (above the tiled ceiling or hard lid ceiling), at 15 locations interspersed throughout all levels of the facility. Of the 15 locations, 13 were found to have penetrations that would not prevent the passage of smoke.

National Fire Protection Association (NFPA) 70, National Electric Code, 2011 Edition
110.26 Spaces About Electrical Equipment. Access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operations and maintenance of such equipment.
(A) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of 110.26 (A)(1), (A)(2), and (A)(3) or as required or permitted elsewhere in this Code.

(1) Depth of Working Space. The depth of the working space in the direction of live parts shall not be less than that specified in Table 110.26 (A)(1) unless the requirements of 110.26 (A)(1)(a), (A)(1)(b), or (A)(1)(c) are met. Distances shall be measured from the exposed live parts or from the enclosure or opening if the live parts are enclosed. (Nominal Voltage to Ground of 0 -150 = 3 feet).

(a) Dead-Front Assemblies. Working space shall not be required in the back or sides of assemblies, such as dead-front switch boards or motor control centers, where all connections and all renewable or adjustable parts, such as fuses or switches, are accessible from locations other than the back or sides. Where rear access is required to work on non-electrical parts on the back of enclosed equipment, a minimum horizontal working space of 762 mm (30 in.) shall be provided.
(b) Low Voltage. By special permission, smaller working spaces shall be permitted where all exposed live parts operate at not greater than 30 volts rms, 42 volts peak, or 60 volt dc.
(c) Existing Buildings. In existing buildings where electrical equipment is being replaced, Condition 2 working clearance shall be permitted between dead-front switch boards, panel boards, or monitor control centers located across the aisle from each other where conditions of maintenance and supervision ensure that written procedures have been adopted to prohibit equipment on both sides of the aisle from being open at the same time and qualified persons who are authorized will service the installation.

Article 314 - Outlet, Device, Pull, and Junction Boxes; Conduit bodies; Fittings; and Handhole Enclosures
314.28(c) Pull and Junction Boxes and Conduit Bodies.
(c) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where used, metal covers shall comply with the grounding requirements of 250.110.

Article 400 - Flexible Cords and Cables
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 the Code
7) Where subject to physical damage

Article 408.4 Field Identification Required
(A) Circuit Directory of Circuit Identification. Every circuit and circuit modification shall be legibly identified as to its clear, evident, and specific purpose or use. The identification shall include an approved degree of detail that allows each circuit to be distinguished from all others. Spare positions that contain unused overcurrent devices or switches shall be described accordingly. The identification shall be included in a circuit directory that is located on the face or inside of the panel door in the case of a panelboard and at each switch or circuit breaker in a switchboard or switchgear. No circuit shall be described in a manner that depends on transient conditions of occupancy.

Based on observation and interview, the facility failed to ensure electrical wiring and equipment complied with the National Electric Code, National Fire Protection Association (NFPA) 70.

Findings include:

1) On 1/8/18 through 1/11/18, during a tour of the facility observation of electrical panelboards revealed that 50 panelboards had inaccurate panelboard directories. Panelboard directories were either:

a) not posted,
b) found to have multiple corrections made by crossing out and hand writing in changes,
c) observed to have permanent marker used to label circuits directly on the metal housing of the panelboard,
d) observed to have an inadequate degree of detail that allowed each circuit to be distinguished from all others.

2) On 1/8/18 through 1/11/18, during a tour of the facility the following junction boxes were found to have missing covers:

a) Room A0026 Electrical Room - 1 junction box was missing its cover.
b) Central Sterile Services Cart Wash Equipment Room - 1 junction box was missing its cover.
c) Nuclear Medicine Hot Lab - 4 junction boxes were missing their covers.
d) Hallway outside of B1177 - above the ceiling tiles in the interstitial space - 2 junction boxes were missing their covers.
e) Hallway outside of C3138 - above the ceiling tiles in the interstitial space - 1 junction box was missing its cover.

3) On 1/8/18 through 1/11/18, during a tour of the facility observation revealed the following relocatable power tap (RPT) and/or extension cord deficiencies:

a) Room F0150 - A RPT was used to power a water cooler, refrigerator and microwave.
b) Room F0152 - A RPT was used to power a refrigerator.
c) Emergency Room Physicians Lounge - A RPT was used to power a microwave and refrigerator.
d) Room E1463 - A RPT was used to power a microwave, 2 refrigerators and water cooler.
e) Room E1430 - A RPT was used to power a microwave.
f) Room D3240 - A RPT was used to power a microwave and coffee pot.

4) On 1/8/18 through 1/11/18, during a tour of the facility observation of Room D1352 revealed two ladders were stored within 3 feet of the front of electrical panel DPLN-D-1-A.

The Director of Facilities and/or the Supervisor of Facilities acknowledged the deficiencies at the time of discovery and during the exit interview.

Based on document review, observation and interview, the facility failed to include in its smoking policy the minimum provisions as outlined in the Life Safety Code (National Fire Protection Association 101, 2012 Edition).

Findings include:

On 1/8/18 at approximately 9:30 AM, a review of the facility's smoking policy revealed it did not include provisions for ashtrays or metal containers.

On 1/8/18 at approximately 9:30 AM, the Director of Facilities acknowledged the deficiency.

On 1/8/18 at approximately 12:30 PM, observation of the exterior portion of the north east entrance to the common dining area on the first floor revealed a gooseneck style smoker's receptacle. Smoker's receptacles were not addressed in the facility's smoking policy.

Based on observation and interview, the facility failed to prohibit the use of space heating devices.

Findings include:

On 1/8/18 through 1/11/18, during the tour of the facility 22 space heating devices were discovered. Neither the staff where the devices were found nor the Director of Facilities were able to produce the specification information for the heating elements. All space heating devices were discovered in nonsleeping staff and employee areas.

The Director of Facilities acknowledged the deficiencies at the time of discovery and during the exit interview.

Based on observation and interview, the facility failed to properly store medical gas (oxygen) as required.

Findings include:

On 1/8/18 through 1/11/18, observation of medical gas (oxygen) storage areas revealed the following deficiencies:

1) Room C0070 - Medical Gas Supply Room - mixed empty with full e-sized tanks. The minimum required wording was not present on the doors.

2) Room F1524 - There were 14 E-sized oxygen cylinders (8 full and 6 empty). The cylinders were not segregated and signage on the racks and the door was not present.

3) Room E3315 - There were 12 E-sized oxygen cylinders (10 full and 2 empty). The cylinders were not segregated and signage on the racks and the door was not present. There were combustibles stored within 5 feet of the oxygen cylinders (paper gowns and assorted boxes of supplies).

4) Room G3450 - There were 15 E-sized oxygen cylinders (14 empty and 1 partial use). The cylinders were not segregated and signage on the racks and the door was not present. There were combustibles stored within 5 feet of the oxygen cylinders (paper gowns and assorted boxes of supplies).

5) Room A3043 - There were 3 E-sized oxygen cylinders (3 full). Signage on the racks and the door was not present.

On 1/11/18 at 11:35 AM, the Respiratory Therapy (RT) Manager explained the RT department is responsible for swapping empty for full medical gas cylinders throughout the facility. The Respiratory Therapy Manager acknowledged that the medical gas cylinders are to be segregated, that combustibles are to be kept 5 feet from the cylinders, and that signs are required.

On 1/11/18 at 11:45 AM, the Director of Facilities acknowledged the deficiencies associated with the storage of medical gas.