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Based upon observation and staff interviews during the physical tour of the facility on 5/4/21 between approximately 0830 and 1230 hours, the facility has failed to maintain the identification and access to Fire Sprinkler system control equipment and fire hydrants in accordance with Washington State law. This could result in the failure of responding fire department personnel to readily identify the fire sprinkler riser control valves or access the facility's fire hydrants, potentially delaying suppression activities during a fire event, which would endanger the patients, staff and/or visitors within the facility.

The findings include:

-There was no identifying signage on the exterior door to the room (1 of 1 doors into the room) containing the facility's fire sprinkler system riser and control valves.

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

Per 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.

Per 2018 International Fire Code 509.1, adopted into Washington State law by RCW 19.27.031: Fire protection equipment shall be identified in an approved manner. Rooms containing controls for air-conditioning systems, sprinkler risers and valves, or other fire detection, suppression or control elements shall be identified for the use of the fire department. Approved signs required to identify fire protection equipment and equipment location shall be constructed of durable materials, permanently installed and readily visible.

-The fire hydrant in the south parking lot was blocked from vehicle and pedestrian access by temporary construction fencing.

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

Per 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.

Per 2018 International Fire Code 507.5.4, adopted into Washington State law by RCW 19.27.031: Unobstructed access to fire hydrants shall be maintained at all times. The fire department shall not be deterred or hindered from gaining immediate access to fire protection equipment or fire hydrants.


The above was discussed and acknowledged by the Maintenance Technician 2 who said they were unaware signage was required on the door to the fire sprinkler riser room and that the construction fencing was obstructing access to the south parking lot fire hydrant.

Based upon observations and staff interviews on 5/4/2021 during the physical tour of the facility between approximately 0830 and 1230 hours, the facility has failed to maintain fire resistive separation between the facility and non-conforming additions as not less than a 2 hour resistance rating. This could result in an unmitigated fire spreading from the non-conforming addition into the facility, which would endanger the patients, staff, and/or visitors within the facility.

The findings include:

-The exit corridor in the south wing of the hospital is connected to a new Rural Health Clinic addition and was observed to only have wood framing and insulation separating the hospital from the addition. Observation from within the Rural Health Clinic indicated a 2-hour fire barrier was present but that no fire doors have been installed in the corridor opening between the facilities. The Rural Health Clinic's fire alarm and fire sprinkler system have not had an acceptance test completed and approved by an Authority Having Jurisdiction.

Per 2012 NFPA 101- 19.1.1.4.1 : Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition.

Per 2012 NFPA 101-19.1.1.4.1.1: Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire door assemblies.

Per 2012 NFPA 101-19.1.3.4.1: Ambulatory care facilities, medical clinics, and similar facilities that are contiguous to health care occupancies, but are primarily intended to provide outpatient services, shall be permitted to be classified as business occupancies or ambulatory health care facilities, provided that the facilities are separated from the health care occupancy by not less than 2-hour fire resistance-rated construction.

The above was discussed and acknowledged by the CFO who said they have completed construction of the 2-hour separation wall between the two facilities, but that the 90 minute fire doors haven't been installed yet due to other portions of the area needing to be completed first.

Based upon observations and staff interviews on 5/4/2021 during the physical tour of the facility between approximately 0830 and 1230 hours the facility has failed to maintain the means of egress as being readily available for full instant use in the event of fire. This could cause an inability or delay in the evacuation of staff in the event of an emergency which would endanger patients, staff, and/or visitors.

The findings include:

-There were multiple full cardboard boxes stacked (approximately 5 feet in height and 5 feet in length) on one side of the basement exit corridor along with other miscellaneous storage items stored in cardboard boxes upon wheeled shelving units on both sides of the basement exit corridor.


The above was discussed and acknowledged by the CFO who stated the majority of the storage was emergency COVID supplies they were trying to find a location to store in and the rest were shipping and receiving items that were loaded and unloaded on a daily basis.

Based upon observation and staff interviews during the inspection of the facility on 5/4/2021 between approximately 0830 and 1230 hours, the facility has failed to maintain the Clean Agent (FM-200) extinguishing system in the imaging lab as required by NFPA 2001. This could result in the failure of the clean agent suppression system to operate properly in the event of a fire which would endanger the patients, staff, and/or visitors within the imaging room and facility.

The findings include:

The Imaging Lab's FM-200 fire extinguishing system's manual activation button was not labeled or identified as required by NFPA 2001-7.7.2.4.10 and the Abort button was not labeled / identified as required by NFPA 2001-7.7.2.4.13.


Per NFPA 101-Table 9.7.3.1 Clean Agent extinguishing systems shall be installed and maintained in accordance with NFPA 2001.

Per 2012 NFPA 2001-7.7.2.4.10: Manual pull stations shall be properly installed, readily accessible, accurately identified, and properly protected to prevent damage.

Per 2012 NFPA 2001-7.7.2.4.13: For systems using abort switches, the switches shall be of the deadman type requiring constant manual pressure, properly installed, readily accessible within the hazard area, and clearly identified. Switches that remain in the abort position when released shall not be used for this purpose. Manual pull stations shall always override abort switches.

The above was discussed and acknowledged by the Maintenance Technician 2 who said they were unaware the manual activation and abort switches were required to be labeled.

Based upon observations and staff interviews on 5/4/2021 during the physical tour of the facility between approximately 0830 and 1230 hours, the facility has failed to maintain doors to hazardous areas as self or automatic closing and able to resist the passage of smoke and fire. This could result in the spreading of the toxic products of combustion into the corridor or use area in the event of a fire which would endanger patients, staff, and/or visitors.

The findings include:


-1 of 1 doors from the Administration storage room over 50 square feet into the PT suite failed to close and latch automatically.



The above was discussed and acknowledged by CFO who said they were unaware the Administration storage room's door was not fully closing and latching automatically.

Based upon observation and staff interviews on 5/4/2021 during the physical tour of the facility between approximately 0830 and 1230 hours, the facility has failed to maintain and install the fire sprinkler system as required by NFPA 13 and NFPA 25. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire which would endanger the patients, staff, and/or visitors within the facility.


The findings include:

-No fire sprinkler coverage was observed in the Autoclave closet (approximately 4' by 8') in the rear of the Lab.

Per 2010 NFPA 13-4.1: A building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas except where specific sections of this standard permit the omission of sprinklers.


The above was discussed and acknowledged by the facility Maintenance Technician 2 who said the missing sprinkler coverage in the closet had not been previously identified.

Based upon observation and staff interviews on 5/4/2021 during the physical inspection of the facility between approximately 0830 and 1230 hours, the facility has failed to maintain the fire sprinkler system as required by NFPA 13 and NFPA 25. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire which would endanger the patients, staff, and/or visitors within the facility.



The findings include:


-There was storage on top of shelving in the basement Lab Storage room, obstructing the spray pattern of the nearby sprinkler head.

Per 2010 NFPA 13-7.7.1.4 : Automatic sprinklers shall not be obstructed by auxiliary devices, piping, insulation, and so forth, from detecting fire or from proper distribution of water.


The above was discussed and acknowledged by the facility Maintenance Technician 2 who said he had not previously observed the storage to be obstructing the sprinkler head.

Based upon observation, document review and staff interviews during the physical tour of the facility on 5/4/2021 between approximately 0830 and 1230 hours, the facility has failed to maintain their portable fire extinguishers as required by NFPA 10. This could result in the failure of the fire extinguishers to operate properly in the event of a fire which would endanger the patients, staff, and/or visitors within the facility.

The findings include:

-The facility was unable to provide documentation indicating all portable extinguishers within the facility have had an annual inspection/maintenance servicing within the last 12 months. The tags on multiple extinguishers indicated they were last inspected/serviced on 4-29-2020

Per NFPA 10, 2010-7.3.1.1.1: 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.

The above was discussed and acknowledged by the facility Maintenance Technician 2 who said they have scheduled the service with a contract provider, but that the contractor would not be able to conduct the work until later in May due to their schedule.

Based upon observations and staff interviews on 5/4/2021 during the physical tour of the facility between approximately 0830 and 1230 hours the facility has failed to properly maintain the Type 1 EES Life Safety Branch in the facility. This could result in a failure of the life safety electrical distribution system and all associated components to include means of egress illumination and the Fire Alarm system, thereby endangering patients, staff, and/or visitors within the facility.

The findings include:

-The Life Safety branch panel LSB in the Business Office Server room served an Air conditioner, Nurse's lounge outlets, Doctor's office lounge outlets, copy room outlets, and the room 117 copier on circuits 12-30.

Per 2012 NFPA 99-6.4.2.2.3.5 No functions other than those in 6.4.2.2.3.2, 6.4.2.2.3.3, and 6.4.2.2.3.4 shall be connected to the life safety branch, except as specifically permitted in 6.4.2.2.3.

The above was discussed and acknowledged by the CFO who said the non-authorized circuits had not been previously identified as being on the life safety branch and that the facility was unaware they could not be on the LSB panel.