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Based on observation and interview, the facility failed to maintain a safe path of egress. This was evidenced by medical beds blocking the mean of egress. During a fire or other emergency, this could delay evacuation and harm patients, visitors, and staff. This affected one of six floors in the Nursing building.

Findings:

During a facility tour with the Engineering Staff, the surveyor observed the means of egress.

Nursing Building.

1. On 3/25/19 at 11:01 a.m., in the North wing on the sixth floor of the Nursing building, five medical beds were stored in the 8 foot corridor, blocking nearly the entire width. The beds blocked access to rooms 6A306 and 6A303. The Hospital Staff (PO3) stated that they were changing beds out and those got left in the corridor.

Based on observation and interview, the facility failed to maintain the hazardous areas. This was evidenced by the failure to install a self closing devices on hazardous room doors and a door with a transfer grill. This could result in the faster spread of smoke and fire to other areas in the event of a fire. This affected one of six floors in the Nurse building, and the Westside and the McKee Family Health Clinic.

Findings:

During a tour of the facility and interview with Hospital Staff, the hazardous areas were observed.

Westside Family Health Center

1. On 3/26/19 at 10:43 a.m., there was a transfer grill installed on the oxygen cylinder storage room door. The room stored more than 12 oxygen 'E' type cylinders and one "H" type cylinders. During a concurrent interview, the Hospital Staff (PO14) stated that they can replace the door without a transfer grill.

2. On 3/26/19 at 11:06 a.m., the clean linen room door was not equipped with a self closing device. During a concurrent interview, the Engineering Staff (ES3) confirmed the finding and stated that the room was larger than 50 square feet.

McKee Family Health Center:

3. On 3/26/19 at 12:25 p.m., the central supply room door was not equipped with a self closing device. During a concurrent interview, the Hospital Staff (PO15) stated that the room was used to receive supplies and was originally designed this way.

Based on observation, the facility failed to ensure their fire alarm manual pull station was continuously accessible. This was evidenced by blocked access to a fire alarm pull station. This could delay notification during a fire, and harm patients, visitors, and staff. This affected one of five floors in the Behavioral Health building.

Findings:

During a facility tour with the Engineering Staff, the surveyor observed the fire alarm system.

Behavioral Health Building.

1. On 3/26/19 at 8:59 a.m., in the Penthouse of the Behavioral Health building, the fire alarm pull station was blocked by copper tubing which had been stacked in a bucket. In addition, an extension cord was coiled around the pull station box.

Based on observation and interview, the facility failed to maintain the fire sprinkler tamper alarms. This was evidenced by a failed tamper alarm for the fire sprinkler when tested. This could result in failure to notify the monitoring station when their fire sprinkler system was tampered. This affected one of six floors of the Nursing Building.

Findings:

During a tour of the facility, the fire sprinkler tamper alarms were tested with the Engineering Staff.

Nursing Building.

1. On 3/26/19 at 3:10 p.m., the tamper alarm located in the stairwell of the Nursing building first floor was tested by the Engineering Staff. When the tamper valve was closed by the Engineering Staff, there was no alarm heard at the fire alarm panel located in the Security Office.

At 3:11 p.m., the Engineering Staff stated that the tamper alarm was recently tested a few weeks ago.

Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system. This was evidenced by the failure to maintain the sprinklers free of debris, the failure to maintain the sprinklers free from obstruction with a minimum of 18-inch clearance below the sprinkler's deflector, by missing a half inch reducer on the inspector test valve (ITV), by a continuous leak found on the ITV, the failure to conduct monthly inspection of the fire sprinkler gauges and valves, and the failure of the test valve gauge to register the correct water pressure. This could affect the operation of the sprinkler system and could delay in extinguishing a fire. This affected three of six floors in the Nursing building, one of five floors in the Diagnostic and Treatment (D&T) building, one of three floors in the Behavioral Health building, and the Fontana Family Health Center.

NFPA 101, Life Safety Code, 2012 Edition
19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection System, 2011 Edition

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.

5.2.4 Gauges.
5.2.4.1* Gauges on wet pipe sprinkler systems shall be inspected
monthly to ensure that they are in good condition and
that normal water supply pressure is being maintained.

NFPA 13, Standard for the Installation of Sprinkler Systems, 2010 Edition

8.5.5.2 * Obstructions to Sprinkler Discharge Pattern Development.
8.5.5.2.1
Continuous or noncontinuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with 8.5.5.2.
8.5.5.2.2
Sprinklers shall be positioned in accordance with the minimum distances and special requirements of Section 8.6 through Section 8.12 so that they are located sufficiently away from obstructions such as truss webs and chords, pipes, columns, and fixtures.
8.5.5.3 * Obstructions That Prevent Sprinkler Discharge from Reaching the Hazard.
Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 8.5.5.3.
8.5.5.3.1
Sprinklers shall be installed under fixed obstructions over 4 ft (1.2 m) wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors.
8.5.5.3.2
Sprinklers shall not be required under obstructions that are not fixed in place such as conference tables.
8.5.5.3.3 *
Sprinklers installed under open gratings shall be of the intermediate level/rack storage type or otherwise shielded from the discharge of overhead sprinklers.
8.5.6 * Clearance to Storage.
8.5.6.1 *
Unless the 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 in. (457 mm) or greater.

Findings:

During a facility tour with Engineering Staff, the surveyor observed the automatic fire sprinkler system.

1. On 3/25/19 at 10:59 a.m., in the Evacuation Storage Room 6A308A, located in the 6th Floor north wing of the Nursing Building, a light fixture was located approximately nine inches from the fire sprinkler deflector, as measured by the Engineering Staff (PO4).

2. On 3/25/19 at 11:23 a.m., in the Clean Linen Room 6A6293B, located in the 6th Floor center wing of the Nursing Building, the fire sprinkler was contaminated with foreign material. At 11:37 a.m., the Engineering Staff (PO3) stated that the sprinkler was missed for cleaning.

3. On 3/25/19 at 11:36 a.m., in the Unit Manager Office 6A291A, located in the 6th Floor south wing Nursing Building, the fire sprinkler was contaminated with foreign material.

4. On 3/25/19 at 1:37 p.m., in the Galley Kitchen, located in the 4th Floor center wing Nursing Building, the fire sprinkler was contaminated with foreign material.

5. On 3/25/19 at 2:16 p.m., in the Staff Lounge, located in the 3rd Floor D&T Building, the fire sprinkler was contaminated with foreign material.


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Fontana Family Health Center:

6. On 3/26/19, at 9:58 a.m., there was a continuous leak coming from the inspector test valve and there was no half inch reducer on the valve. During a concurrent interview, the Hospital Staff (PO7) and (PO12) confirmed the finding. Hospital Staff (PO7) stated that the valve was closed off with a screw nut to prevent access to the public.

Behavioral Health, Second Floor, South Unit:

7. On 3/26/19, at 2:40 p.m., there was accumulation of dust and debris on a sprinkler head next to Room 2811. During a concurrent interview, Hospital Staff (PO10) confirmed the finding.








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8: On 3/25/2019, the fire sprinkler maintenance documentation for all buildings were reviewed with the Engineering Staff. At 2 p.m., there was no documentation for the required monthly inspection of the gauges. At 2:05 p.m., the Engineering Staff stated that they have not been doing the inspection every month.

9. On 3/26/2019, the fire sprinkler inspector test valve was tested with the Engineering Staff at the Nursing Building. At 2:50 p.m., the inspector test valve located in the second floor stairwell of the Nursing Building was tested. When the valve was opened by the Engineering Staff, the pressure gauge needle went down from 100 pound per square inch (psi) to 0 psi. There was a sound of gushing water from the water pipe. At 2:51 p.m., the Engineering Staff stated that the valve were recently tested on their 5 year fire sprinkler certification. He stated that the valve must be at fault.

Based on observation and interview, the facility failed to maintain the portable fire extinguishers. This was evidenced by the failure to inspect the extinguishers for 2 of 12 months in the Westside clinic, and the failure to conduct an annual inspection of the fire extinguishers in the McKee clinic. This could result in the device to malfunction in the event of a fire. This affected the Westside and the McKee Family Health Centers.

NFPA 101, Life Safety Code, 2012 Edition
19.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.
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, Standard for Portable Fire Extinguishers, 2010 Edition
7.2.4 Inspection Record Keeping.
7.2.4.3 Where at least monthly manual inspections are conducted, the date the manual inspection was performed the initials of the person performing the inspection shall be recorded.
7.2.4.4 Where manual inspections are conducted, records for manual inspections shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or by an electronic method.
7.3.1.1.1 Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection or electronic notification.

Findings:

During a tour of the facility with the Engineering Staff, the fire extinguishers were observed.

Westside Family Health Clinic:

1. On 3/26/19 at 10:45 a.m., the fire extinguishers were missing monthly inspections in August and December 2018. During a concurrent interview, the Engineering Staff (PO13) confirmed the finding and stated that the building landlord was responsible for checking the fire extinguishers.

McKee Family Health Clinic:

2. On 3/26/19 at 12:15 p.m., the fire extinguishers were missing the annual inspection. There were a total of 15 fire extinguishers in the building. The most recent service tags on the fire extinguishers were dated January 2018. During a concurrent interview, the Engineering Staff (PO15) confirmed the finding and stated that the vendor will conduct the annual inspection in two weeks.

Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by doors which failed to self-close and latch, and by doors propped open with furniture and other devices. During a fire, this could allow smoke and flames to pass through the open door and harm patients, visitors, and staff. This affected four of six floors in the Nursing building, one of three floors in the Clinics building, and two of three floors in the Behavioral Health building.

NFPA 101, Life Safety Code, 2012 Edition
19.2 Means of Egress Requirements.
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11.
7.1.10.1* General. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Findings:

During a facility tour with the Engineering Staff, the surveyors observed the self-closing doors.

Nursing Building

1. On 3/25/19 at 11:29 a.m., the door to the Data Room 6A184A, located in the sixth floor south wing of the Nursing building, failed to self-close and latch. The Hospital Staff (PO3) stated that the door needed to be lube and adjusted.

2. On 3/25/19 at 11:42 a.m., the door to the Environmental Services Room 5A304A, located in the fifth floor north wing of the Nursing building, failed to self-close and latch.

3. On 3/25/19 at 1:46 p.m., the door to the Oxygen Room 4A291A, located in the fourth floor center wing of the Nursing building, did not have a self-closing device. The room contains oxygen cylinders and was identified as a hazardous storage area.

Clinics Building

4. On 3/26/19 at 10:49 a.m., the Stair 11 Roof Access door, located in the third floor Penthouse of the Clinics building, failed to self-close and latch.

5. On 3/26/19 at 11:20 a.m., the Stair Seven door 1CST7A, located in the first floor Clinics building, failed to self-close and latch. Hospital Staff (PO3) stated that the door had a pressure imbalance.

D & T Building.

6. On 3/27/19 at 8:55 a.m., the door to the Catering Storage room, located by the Kitchen in the Diagnostic and Treatment building (D&T), was propped open by a bungee cord.

Nursing Building, First Floor:

7. On 3/25/19, at 10:10 a.m., one of two Insurance Verification doors failed to self-close and latch. Two attempts were made. During a concurrent interview, the Hospital Staff (PO7) confirmed the finding.

Behavioral Health, First Floor, South Unit:

8. On 3/25/19, at 1:40 p.m., the dining room door was propped open with a round table. The door was equipped a self closing device. During a concurrent interview, the Hospital Staff (PO8) stated that the door was kept open to help their patients know activities was open.

Behavioral Health, First Floor, North Unit:

9. On 3/25/19, at 2:26 p.m., the dining room door was propped open with a chair. The door was equipped with a self closing device. During a concurrent interview, the Hospital Staff (PO9) confirmed the finding.

Behavioral Health, Second Floor, South Unit:

10. On 3/25/19, at 2:49 p.m., the patient room 2801 was obstructed with a three-seat bench which prevented the door to latch. The patient room door was equipped with a self closing device. During a concurrent interview, the Hospital Staff (PO10) stated the door was kept open to observed the patient and confirmed the patient was not one to one.

Behavioral Health, Second Floor, North Unit:

11. On 3/25/19, at 2:55 p.m., the dining room door was propped open with a chair. The door was equipped with a self closing device. During a concurrent interview, the Hospital Staff (PO11) confirmed the finding.

Hyperbaric

12. On 3/25/19 at 3:40 p.m., the door leading from the Hyperbaric facility to the corridor failed to self-close and latch. The surveyor tested the door three times. The Hospital Staff stated that the door sometimes gets pressured and will not latch.

Based on observation and interview, the facility failed to maintain the integrity of the building structure to resist the passage of smoke. This was evidenced by an unsealed penetration in the fire barrier wall with a conduit pipe running through it. This could result in the spread of smoke and fire causing smoke inhalation and burns to patients, staff and visitors. This affected one of six floors in the Nurse Nurse Tower.

Findings:

During a tour of the facility with the Engineering Staff (ES3) and Hospital Staff (PO7), the interior finish and smoke barrier construction was observed.

Nursing Building, First Floor:

1. On 3/25/19 at 10:43 a.m., there was an unsealed circular penetration in the smoke barrier wall measuring approximately 5 inch in diameter. There was a 2 inch conduit pipe running through the penetration exposing an unsealed space surrounding the conduit pipe. The penetration was noted on both sides of the wall and the wall was located above the smoke barrier doors next to the Rehabilitation Department. During a concurrent interview, Hospital Staff (PO7) acknowledged the finding.

Based on interview, the facility failed to ensure that staff had knowledge of the proper fire protection procedures. This was evidenced by kitchen staff that could not determine the correct fire extinguisher to use for an electrical fire and the failure to correctly classify the extinguisher for a grease fire. This could result in the rapid spread of fire and injury to staff since the extinguishing agents in many Class K extinguishers are electrically conductive, and could delay the staff in using the correct extinguisher during a grease fire. This affected one of five floors in the Diagnostic and Treatment (D&T) Building.

Findings:

During a facility tour with the Engineering Staff, the surveyor interviewed staff to determine their knowledge and usage of life safety equipment.

1. On 3/27/19 at 8:47 a.m., Hospital Staff (PO6) was asked which extinguisher he would use in an electrical fire. He stated that he would use the silver one, referring to the K-type extinguisher. Hospital Staff (PO5) stated that PO6 was a part-time employee.

2. On 3/27/19 at 8:45 a.m., Hospital Staff (PO7) was asked which extinguisher he would use in a grease fire. He stated he would use the silver extinguisher but referred to it as ABC Class.









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Diagnostic and Treatment (D&T) Building

3. On 3/27/19 at 8:45 a.m., Hospital Staff (PO16) was asked which extinguisher he would use in a grease fire. He stated that he would use the silver extinguisher but referred to it as ABC Class.

Based on observation, the facility failed to maintain electrical safety. This was evidenced by the use of electrical devices hanging mid-air, tensioned by their electrical cords, and by the use of a multi-outlet adapter. This could cause shorting, electrical overload, sparking, smoke and flames, and could harm patients, visitors, and staff. This affected one of six floors in the Nursing Building.

NFPA 101, Life Safety Code, 2012 Edition

19.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.
9.1.2 Electric. 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, National Electrical Code, 2011 Edition
400.10 Pull at Joints and Terminals.
Flexible cords and cables shall be connected to devices and to fittings so that tension is not transmitted to joints or terminals.

Findings:

During a facility tour with Engineering Staff, the surveyor observed the electrical wiring and equipment.

1. On 3/25/19 at 11:53 a.m., in the Conference Room 5A395A, located in the 5th floor north wing of the Nursing Building, an electrical adapter was held vertically by multiple electrical cords which were coiled and hanging vertically. The cords were both black and orange and were tied together by a piece of velcro.

2. On 3/25/19 at 1:13 p.m., in room 5A212A, labeled "Family Conference" but used as the Deputy Office, located in the 5th floor center wing of the Nursing Building, a printer, monitor, and a docking station were connected to a power strip which was hanging mid-air, tensioned by the cords of the electrical devices.

3. On 3/25/19 At 1:37 p.m., in Office 5A106A, located in the 5th floor south wing of the Nursing Building, a microwave oven was connected to a three-outlet adapter, which was then connected to the duplex receptacle wall outlet.

Based on observation, the facility failed to maintain the gas equipment. This was evidenced by oxygen storage rooms which could not be secured from unauthorized access. This could allow unauthorized persons to access the oxygen cylinders, and harm residents, visitors, and staff. This affected two of six floors in the Nursing building, and one of five floors in the Diagnostic and Treatment (D&T) building.

NFPA 99, Health Care Facilities Code, 2012 Edition
11.3 Cylinder and Container Storage Requirements.
11.3.2.1
Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.

Findings:

During a facility tour with Hospital Staff, the surveyor observed the gas cylinder storage rooms.

1. On 3/25/19 at 1:18 p.m., the door to Oxygen Cylinder Storage Room 5A291A, located in the Fifth Floor Center Wing of the Nursing Building, had no locking mechanism.

2. On 3/25/19 at 1:46 p.m., the door to Oxygen Cylinder Storage Room 4A291A, located in the Fourth Floor Center Wing of the Nursing Building, had no locking mechanism.

3. On 3/25/19 at 2:10 p.m., the door to the Oxygen Cylinder Storage Room, located inside Storage Room 3B270A, which was located on the Third Floor of the D&T building, had no locking mechanism.