HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by unsealed penetrations in the wall. This affected one of two buildings and could result in the r spread of smoke or fire to other locations in the event of a fire.

Findings:

During a facility tour with Engineer 1 (ES1) on 7/11/17, the walls were observed.

Medical Outpatient Building

At 9:43 a.m., there were nine wall penetrations measuring approximately 1 inch to 3 inches around pipes in the Electrical Room. The finding was confirmed by ES1.

Based on observation, document review, and interview, the facility failed to maintain the battery back-up combination emergency exit sign with lights. This was evidenced by the emergency light on the exit sign that failed to illuminate, and by no annual testing of the combination exit sign and lights. This affected one of two buildings, and could result in delayed evacuation in the event of an emergency.

NFPA 101, Life Safety Code, 2012 Edition
19.2.9 Emergency Lighting.
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9
7.9.3 Periodic Testing of Emergency Lighting Equipment.
7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.
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).
(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 1 1?2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
7.9.3.1.2 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall be provided.
(2) Not less than once every 30 days, self-testing/self-diagnostic
battery-operated emergency lighting equipment shall automatically perform a test with a duration of a minimum of 30 seconds and a diagnostic routine.
(3) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall indicate failures by a status indicator.
(4) A visual inspection shall be performed at intervals not exceeding 30 days.
(5) Functional testing shall be conducted annually for a minimum of 1 1?2 hours.
(6) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall be fully operational for the duration of the 1 1?2-hour test.
(7) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
7.9.3.1.3 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Computer-based, self-testing/self-diagnostic battery operated emergency lighting equipment shall be provided.
(2) Not less than once every 30 days, emergency lighting equipment shall automatically perform a test with a duration of a minimum of 30 seconds and a diagnostic routine.
(3) The emergency lighting equipment shall automatically perform annually a test for a minimum of 1 1?2 hours.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.3(2) and (3).
(5) The computer-based system shall be capable of providing a report of the history of tests and failures at all times.

Findings:

During a tour of the facility, document review, and interview with Engineer 1 (ES1) on 7/11/17, the battery back-up combination emergency exit sign with light was observed and maintenance record was requested.

Medical Outpatient Building:

1. At 9:18 a.m., a battery back-up combination emergency exit sign with light located at the entrance to Suite A, was observed. When the test button was pressed, the light failed to illuminate.

2. At 11:16 a.m., the facility was not able to provide annual 90 minute testing of the battery back-up combination emergency exit sign with light. The last annual 90 minute test was conducted on 6/2/16. Upon interview, ES1 confirmed that there was no current annual test.

Based on observation, document review, and interview, the facility failed to maintain the exit signs. This was evidenced by failure to conduct functional test of the battery-powered emergency exit signs. This affected one of two buildings, and could result in delayed evacuation in the event of an emergency.

NFPA 101, Life Safety Code, 2012 Edition
19.2.10 Marking of Means of Egress.
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4.

7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days or shall be periodically monitored in accordance with 7.9.3.1.3.

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 Periodic Testing of Emergency Lighting Equipment.
7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.

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).
(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During a tour of the facility, document review, and interview with Engineer 1 (ES1) on 7/11/17, the exit signs were observed, documents were requested, and staff was interviewed.

At 10:30 a.m., the facility failed to provide documentation for the required monthly and annual functional test of the battery-powered emergency exit signs. The facility has 32 battery-powered emergency exit signs throughout the Monterey and Shasta units. When interviewed, ES1 stated that there were no monthly and annual testing for the battery-powered emergency exit signs.

Based on observation, document review, and interview, the facility failed to maintain their kitchen suppression system. This was evidenced by the failure to provide the inspection records for the kitchen wet solution extinguishing unit. This affected one of two buildings. This could result in the kitchen suppression system to malfunction in the event of an emergency.

NFPA 101, Life Safety Code, 2012 Edition
19.3.2.5 Cooking Facilities.
19.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3, unless otherwise permitted by 19.3.2.5.2, 19.3.2.5.3, or 19.3.2.5.4.

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, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 Edition
11.2 Inspection, Testing, and Maintenance of Fire-Extinguishing Systems.
11.2.3 The specific inspection and maintenance requirements of the extinguishing system standards as well as the applicable installation and maintenance manuals for the listed system and service bulletins shall be followed.


Findings:

During a tour of the facility, document review, and interview with Engineer 1 (ES1) on 7/12/17, the kitchen suppression system was observed, documents were requested, and staff was interviewed.

At 11:10 a.m., the facility failed to provide the monthly inspection of the wet chemical solution extinguishing system unit for the kitchen suppression system. The wet chemical solution unit was MODEL WHDR-600. The maintenance on the unit read "INSPECT MONTHLY OR MORE FREQUENTLY WHEN CIRCUMSTANCES REQUIRE". When interviewed, ES1 stated that he was unaware of the monthly inspection requirement for the wet chemical solution unit.

Based on observation, the facility failed to maintain the fire alarm system. This was evidenced by the main fire alarm control panel (FACP) that was obstructed from access. This could result in staff inability to access the FACP in the event of an emergency. This affected one of two buildings.

NFPA 101, Life Safety Code, 2012 Edition
9.6 Fire Detection, Alarm, and Communications Systems.
9.6.1* General.
9.6.1.1 The provisions of Section 9.6 shall apply only where specifically required by another section of this Code.
9.6.1.2 Fire detection, alarm, and communications systems installed to make use of an alternative permitted by this Code shall be considered required systems and shall meet the provisions of this Code applicable to required systems.
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.
9.6.1.4 All systems and components shall be approved for the purpose for which they are installed.
9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition
10.16.3* Annunciator Access and Location.
10.16.3.1 All required annunciation means shall be readily accessible to responding personnel.

Findings:

During a tour of the facility with Engineer 1 (ES1) on 7/12/17, the FACP was observed.

At 9:44 a.m., the access to the main FACP was obstructed by two vital machines that were placed directly in front of the main FACP. The main FACP was located on the second floor. ES1 moved the machines in order to open the door to the FACP. This finding was confirmed by ES1.

Based on observation, and interview, the facility failed to maintain the fire alarm system notification devices. This was evidenced by a fire alarm bell/chime device that failed to emit an audible alarm when the fire alarm system was activated and evidenced by outdated batteries for the Fire Alarm Control Panel (FACP) Booster Power Supply. This affected two of two buildings. and could result in a delayed notification of a fire.

NFPA 101, Life Safety Code, 2012 Edition
9.6 Fire Detection, Alarm, and Communications Systems.
9.6.1* General.
9.6.1.1 The provisions of Section 9.6 shall apply only where specifically required by another section of this Code.
9.6.1.2 Fire detection, alarm, and communications systems installed to make use of an alternative permitted by this Code shall be considered required systems and shall meet the provisions of this Code applicable to required systems.
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.
9.6.1.4 All systems and components shall be approved for the purpose for which they are installed.
9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.
19.3.4.3.1 Occupant Notification. Occupant notification shall be accomplished automatically in accordance with 9.6.3, unless otherwise modified by the following:
(1)*In lieu of audible alarm signals, visible alarm-indicating appliances shall be permitted to be used in critical care areas.
(2) Where visual devices have been installed in patient sleeping areas in place of an audible alarm, they shall be permitted where approved by the authority having jurisdiction.

9.6.3 Occupant Notification.
9.6.3.1 Occupant notification shall be provided to alert occupants of a fire or other emergency where required by other sections of this Code.

9.6.3.7 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level that exists under normal conditions of occupancy.

9.6.3.8 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in a given building.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition
Table 14.4.5 Testing Frequencies
(c) Sealed lead-acid type 6d
(1) Charger test (Replace battery within 5 years after manufacture or more frequently
as needed.)

Findings:

During testing and interview with Engineer 1 (ES1), Maintenance Staff 1 (MS1), and Chief Financial Officer 1 (CFO1) on 7/12/17 thru 7/13/17, the fire alarm chimes and Fire Alarm Control Panel (FACP) Booster Power Supply were observed.

1. On 7/12/17 at 10:44 a.m., four sealed-lead acid batteries in the Fire Alarm Booster Power Supply located in the Transfer Switch Room, were dated 1/13/11. When interviewed, MS1 stated that the batteries were still okay, because it was checked by their vendor.

2. On 7/13/17 at 10:51 a.m., the bell unit for the fire alarm system near the Nurse Station in Unit A, failed to omit an audible alarm upon the activation for the fire alarm system. Unit A was located on the third floor. This finding was confirmed by Engineer 2 (ES2).

3. On 7/13/17 at 11:01 a.m., the bell unit for the fire alarm system near Room 216 in Unit D, failed to omit an audible alarm upon the activation for the fire alarm system. Unit D was located on the second floor. This finding was confirmed by ES2.

4. On 7/13/17 at 11:03 a.m., the bell unit for the fire alarm system near Room 209 in Unit C, failed to omit an audible alarm upon the activation for the fire alarm system. Unit D was located on the second floor. This finding was confirmed by ES1.

Based on document review, the facility failed to prepare staff in the event that their fire alarm system was out of service. This was evidenced by the facility failure to indicate that they would contact the California Department of Public Health in the event that their fire alarm system was out of service for more than 4 hours in a 24-hour period. This affected two of two buildings, and could result in a delay in notification in the event of an emergency with the fire alarm system.

Findings:

During document review with Engineer 1 (ES1) on 7/11/17, the facility fire watch procedure for the fire alarm system was reviewed.

At 10:53 a.m., the facility fire watch policy and procedure was reviewed. The fire watch policy and procedure did not indicate that the facility would contact the California Department of Public Health in the event that their fire alarm system went out of service. ES1 confirmed the finding.

Based on observation and interview, the facility failed to maintain the smoke detection system. This was evidenced by a smoke detector that was covered with plastic. This could lead to a malfunction of the smoke detection system in the event of an emergency and affected one of two buildings.

Findings:

During a tour of the facility and interview with Engineer 1 (ES1) and Engineer 2 (ES2) on 7/13/17, the device was observed, and staff was interviewed.

At 11:00 a.m., the smoke detector along the corridor near Room 216, was covered with plastic. The smoke detector was located on the second floor. When interviewed, ES1 stated that the corridor was being painted.

Based on observation, document review, and interview, the facility failed to maintain their automatic sprinkler system. This was evidenced by failure to maintain sprinkler heads, by failing to complete monthly visual inspections of components to the sprinkler system, and by failure to provide an identification sign to the sprinkler system valve. This could affect the operation of the sprinkler system and delay notification of a fire in the event of a fire. This affected two of two buildings.

NFPA 101, Life Safety Code, 2012 Edition
4.6.12 Maintenance, Inspection, and Testing. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire resistive construction, or any other feature is required for compliance with the provision of this code, such device, equipment, system, condition, arrangement, level of protection, fire resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements as directed by the authority having jurisdiction.

9.6 Fire Detection, Alarm, and Communications Systems.
9.6.1* General.
9.6.1.1 The provisions of Section 9.6 shall apply only where specifically required by another section of this Code.

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.

9.7.4.2 Where required by the provisions of another section of this Code, standpipe and hose systems shall be provided in accordance with NFPA 14, Standard for the Installation of Standpipe and Hose Systems. Where standpipe and hose systems are installed in combination with automatic sprinkler systems, installation shall be in accordance with the appropriate provisions established by NFPA 13, Standard for the Installation of Sprinkler Systems, and NFPA 14, Standard for the Installation of Standpipe and Hose Systems.

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.

9.7.7 Documentation. All required documentation regarding the design of the fire protection system and the procedures for maintenance, inspection, and testing of the fire protection system shall be maintained at an approved, secured location for the life of the fire protection system.

9.7.8 Record Keeping. Testing and maintenance records required by NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, shall be maintained at an approved, secured location.

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

5.2.1 Sprinklers.
5.2.1.1* Sprinklers shall be inspected from the floor level annually.
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
(6) Painting unless painted by the sprinkler manufacturer

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.

5.2.1.1.6* Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.

5.2.1.1.7 Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

5.2.1.2* The minimum clearance required by the installation standard shall be maintained below all sprinkler deflectors.

5.2.1.3 Stock, furnishings, or equipment closer to the sprinkler deflector than permitted by the clearance rules of the installation standard shall be corrected.

5.2.1.4 The supply of spare sprinklers shall be inspected annually for the following:
(1) The correct number and type of sprinklers as required by 5.4.1.4 and 5.4.1.5
(2) A sprinkler wrench for each type of sprinkler as required by 5.4.1.6

5.2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level.

5.2.3* Hangers and Seismic Braces. Sprinkler pipe hangers and seismic braces shall be inspected annually from the floor level.

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.

5.2.8* Information Sign. The information sign shall be inspected annually to verify that it is securely attached and is legible.

5.4.1.9 Sprinklers and automatic spray nozzles used for protecting commercial-type cooking equipment and ventilating systems shall be replaced annually.

5.4.1.9.1 Where automatic bulb-type sprinklers or spray nozzles are used and annual examination shows no buildup of grease or other material on the sprinklers or spray nozzles, such sprinklers and spray nozzles shall not be required to be replaced.

13.3.2.1.1 Valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly.

13.3.2.1.2 After any alterations or repairs, an inspection shall be made by the property owner or designated representative to ensure that the system is in service and all valves are in the normal position and properly sealed, locked, or electrically supervised.

13.3.2.2* The valve inspection shall verify that the valves are in the following condition:
(1) In the normal open or closed position
(2)*Sealed, locked, or supervised
(3) Accessible
(4) Provided with correct wrenches
(5) Free from external leaks
(6) Provided with applicable identification

13.4.1.1* Alarm valves and system riser check valves shall be externally inspected monthly and shall verify the following:
(1) The gauges indicate normal supply water pressure is being maintained.
(2) The valve is free of physical damage.
(3) All valves are in the appropriate open or closed position.
(4) The retarding chamber or alarm drains are not leaking.

Findings:

During a tour of the facility, document review, and interview with Engineer 1 (ES1) on 7/11/17 thru 7/12/17, the sprinkler system testing and inspection records were requested, sprinklers were observed, and staff was interviewed.

1. On 7/11/17 at 1:20 p.m., the facility failed to provide records for the monthly inspections of the sprinkler gauges and valves during the survey. When interviewed, ES1 stated that there were no monthly inspections but quarterly inspections and test are conducted.

2. On 7/12/17 at 9:48 a.m., the escutcheon in the Nurse Station restroom, was not flush with ceiling. The Nurse station was located on the second floor. The escutcheon dropped approximately 1/3 inch from the ceiling. This finding was confirmed by ES1.

3. On 7/12/17 at 9:58 a.m., there was no weatherproof metal identification sign for the Inspector's Test Valve (ITV), located on the second floor in the Linen Storage room. When interviewed, ES1 stated that there was a sign, but was unsure what happened to it.

4. On 7/12/17 at 11:00 a.m., the escutcheon in the walk-in refrigerator located in the Kitchen on the first floor, was not flush with ceiling. There was an approximately 1 inch penetration at the side of the escutcheon in the ceiling. This finding was confirmed by ES1

5. On 7/12/17 at 9:12 a.m., there was a missing escutcheon ring and paint on the deflector in the Seclusion Bathroom, located at the Nurse Station, third floor. This finding was confirmed by CFO1.

6. On 7/12/17 at 10:13 a.m., there was a bag of clothes stored approximately six inches from the sprinkler deflector in the Laundry Room, first floor. This finding was confirmed by MS.

7. On 7/12/17 at 10:25 a.m., there was a box, stored approximately eight inches below the sprinkler deflector in the Infusion Supply Closet in Room 110. This finding was confirmed by MS.



31203

Based on document review, and interview, the facility failed to prepare themselves in the event that their automatic sprinkler system was out of service. This was evidenced by the failure to indicate that the facility would contact the California Department of Public Health in the event that their automatic sprinkler system went out of service for more than 10 hours in a 24-hour period. This affected four of four buildings, and could result in delayed notification in the event of an emergency with the automatic sprinkler system.

Findings:

During document review with Engineer 1 (ES1)on 7/11/17, the facility fire watch policy for the automatic sprinkler system was reviewed.

At 10:55 a.m., the fire sprinkler system out of service procedure was reviewed. The fire watch procedure did not indicate that the facility would contact the California Department of Public Health in the event that their automatic sprinkler system went out of service for more than 10 hours in a 24 hour period. ES1 confirmed the finding.

Based on observation, and interview, the facility failed to maintain their fire extinguishers. This was evidenced by unsecured fire extinguishers. This could result in the fire extinguisher being knocked over and damaged, and/or unable to extinguish a fire. This affected one of two buildings.

NFPA 101, Life Safety Code, 2012 Edition
9.7.4 Manual Extinguishing Equipment.
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
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.

Findings:

During a tour of the facility with the Maintenance Staff 1 (MS1), and the Chief Financial Officer 1 (CFO1) on 7/12/17, the fire extinguishers were observed.

1. At 10:23 a.m., the fire extinguisher in the Data Room by Room 110, was observed freestanding and unsecured on the floor. The finding was confirmed by MS1.

2. At 10:46 a.m., the fire extinguisher in the Maintenance Shop, was observed freestanding and unsecured on the floor. When interviewed, ES1 stated that the fire extinguisher was removed from the third floor because the patient ripped off the cabinet, and staff was in the process for repairing the cabinet.

Based on observation, and interview, the facility failed to maintain corridor doors to resist the passage of smoke and/or fire. This was evidenced by a door that failed to latch, and by a door that was obstructed from closing. This affected two of two buildings, and could result in the passage smoke and flames in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition
19.3.6.3* Corridor Doors.
19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following:
(1) 13?4 in. (44 mm) thick, solid-bonded core wood
(2) Material that resists fire for a minimum of 20 minutes

19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply:
(1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.
(2) Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7.

19.3.6.3.10* Doors shall not be held open by devices other than those that release when the door is pushed or pulled.

7.2.1.8 Self-Closing Devices.
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.

7.2.1.5 Locks, Latches, and Alarm Devices.
7.2.1.5.1 Door leaves shall be arranged to be opened readily from the egress side whenever the building is occupied.
7.2.1.5.2* The requirement of 7.2.1.5.1 shall not apply to door leaves of listed fire door assemblies after exposure to elevated temperature in accordance with the listing, based on laboratory
fire test procedures.
7.2.1.5.3 Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
7.2.1.5.4 The requirements of 7.2.1.5.1 and 7.2.1.5.3 shall not apply where otherwise provided in Chapters 18 through 23.

Findings:

During a tour of the facility, and interview with Engineer 1 (ES1) on 7/11/17 thru 7/12/17, the corridor doors were observed.

Medical Outpatient Building:

1. On 7/11/17 at 9:22 a.m., the door to the Men's bathroom located in Suite B/C/D, was equipped with a self-closing device, that failed to latch when fully opened and released. The door was tested three times, and failed. When interviewed, ES1 confirmed the finding, and stated that a rubber bumper on the door frame prevented the door from latching.

2. On 7/11/17 at 9:43 a.m., the door to the Electrical Room, was equipped with a self-closing door device, that failed to latch when fully opened and closed. When interviewed, ES1 stated that the self-closure device was bent down.

Main Hospital

3. On 7/12/17 at 9:11 a.m., the door to Room 311 located on the third floor, was propped open by a chair. When interviewed, ES1 stated that the door was propped open for closer observation of the patient.

Based on observation, and interview, the facility failed to maintain the smoke integrity of the smoke barrier walls. This was evidenced by an unsealed penetration in the smoke barrier wall. This could result in the spread of smoke and fire in the event of a fire. This affected one of two buildings.

NFPA 101, Life Safety Code, 2012 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2-hour fire resistance rating, unless otherwise permitted by one of the following:
(1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:
(a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c).
(b) Not less than two separate smoke compartments shall be provided on each floor.
(2) Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier.

8.5.6.2 Penetrations for cables, cable trays, conduits, pipes, tubes, 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 smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.

8.5.6.3 Where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8.3.5 to limit the spread of fire for a time period equal to the fire resistance rating of the assembly and 8.5.6 to restrict the transfer of smoke, unless the requirements of 8.5.6.4 are met.

Findings:

During a tour of the facility, and interview with Maintenance Staff 1 (MS1) on 7/12/17, the smoke barrier wall was observed.

Main Hospital

At 11:52 a.m., there was an approximately one inch unsealed penetration, underneath data wires going through the smoke barrier wall near Room 211, located on the second floor. When interviewed, MS1 confirmed the finding, and stated that he would have the penetration sealed.

Based on observation, the facility failed to maintain their fire doors. This was evidenced by smoke barrier doors that failed to latch. This could result in the spread of smoke and fire in the event of a fire. This affected one of two buildings.

NFPA 101, Life Safety Code, 2012 Edition
19.2.2.2.7* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2, shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

7.2.1.8 Self-Closing Devices.
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 holdopen 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

7.2.1.15 Inspection of Door Openings.
7.2.1.15.1* Where required by Chapters 11 through 43, the following door assemblies shall be inspected and tested not less than annually in accordance with 7.2.1.15.2 through 7.2.1.15.8:
(1) Door leaves equipped with panic hardware or fire exit hardware in accordance with 7.2.1.7
(2) Door assemblies in exit enclosures
(3) Electrically controlled egress doors
(4) Door assemblies with special locking arrangements subject to 7.2.1.6

7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives.
7.2.1.15.3 The inspection and testing interval for fire-rated and nonrated door assemblies shall be permitted to exceed 12 months under a written performance-based program in accordance with 5.2.2 of NFPA 80, Standard for Fire Doors and Other Opening Protectives.
7.2.1.15.4 A written record of the inspections and testing shall be signed and kept for inspection by the authority having jurisdiction.
7.2.1.15.5 Functional testing of door assemblies shall be performed by individuals who can demonstrate knowledge and understanding of the operating components of the type of door being subjected to testing.
7.2.1.15.6 Door assemblies shall be visually inspected from both sides of the opening to assess the overall condition of the assembly.
7.2.1.15.7 As a minimum, the following items shall be verified:
(1) Floor space on both sides of the openings is clear of obstructions, and door leaves open fully and close freely.
(2) Forces required to set door leaves in motion and move to the fully open position do not exceed the requirements in 7.2.1.4.5.
(3) Latching and locking devices comply with 7.2.1.5.
(4) Releasing hardware devices are installed in accordance with 7.2.1.5.10.1.
(5) Door leaves of paired openings are installed in accordance with 7.2.1.5.11.
(6) Door closers are adjusted properly to control the closing speed of door leaves in accordance with accessibility requirements.
(7) Projection of door leaves into the path of egress does not exceed the encroachment permitted by 7.2.1.4.3.
(8) Powered door openings operate in accordance with 7.2.1.9.

During fire alarm testing with Engineer 1 (ES1), Maintenance Staff 1 (MS1), and Chief Financial (CFO1) on 7/13/17, the smoke barrier doors were observed.

At 11:00 a.m., the smoke barrier doors in C Unit on the second floor, failed to release from the magnetic hold-open device upon activation of the fire alarm system. The finding was confirmed by ES1.

Based on observation, the facility failed to maintain their electrical equipment. This was evidenced by a receptacle faceplate that was not maintained. This affected one of two buildings, and could result in the ignition of an electrical fire.

NFPA 101, Life Safety Code, 2012 Edition
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.
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, National Electrical Code, 2011 Edition
314.25 Covers and Canopies. In completed installations, each box shall have a cover, faceplate, lampholder, or luminaire canopy, except where the installation complies with 410.24(B).
406.6 Receptacle Faceplates (Cover Plates). Receptacle faceplates shall be installed so as to completely cover the opening and seat against the mounting surface. Receptacle faceplates mounted inside a box having a recess-mounted receptacle shall effectively close the opening and seat against the mounting surface.

Findings:

During a tour of the facility with Engineer 1 (ES1) on 7/12/17, the electrical equipment was observed.

At 10:17 a.m., the receptacle faceplate in the Conference room in the Shasta unit, was not flush with wall. The Shasta unit was located on the first floor. This finding was confirmed by ES1.

Based on observation, document review, and interview, the facility failed to ensure that all staff were familiar with the emergency fire response procedures. This was evidenced by failure to provide a written fire procedure for the facility's secured areas. This affected two of two buildings, and could result in a delayed staff response in the event of a fire, or other emergency.

NFPA 101, Life Safety Code, 2012 Edition
19.7* Operating Features.
19.7.1 Evacuation and Relocation Plan and Fire Drills.
19.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary.

19.7.1.2 All employees shall be periodically instructed and kept informed with respect to their duties under the plan required by 19.7.1.1.

19.7.1.8 Employees of health care occupancies shall be instructed in life safety procedures and devices.

19.7.2 Procedure in case fire
19.7.2.1* Protection of Patients.
19.7.2.1.1 For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel.

19.7.2.1.2 The basic response required of staff shall include the following:
(1) Removal of all occupants directly involved with the fire emergency
(2) Transmission of an appropriate fire alarm signal to warn other building occupants and summon staff
(3) Confinement of the effects of the fire by closing doors to isolate the fire area
(4) Relocation of patients as detailed in the health care occupancy's fire safety plan

19.7.2.2 Fire Safety Plan. A written health care occupancy fire safety plan shall provide for all of the following:
(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire

19.7.2.3 Staff Response.
19.7.2.3.1 All health care occupancy personnel shall be instructed in the use of and response to fire alarms.

19.7.2.3.2 All health care occupancy personnel shall be instructed in the use of the code phrase to ensure transmission of an alarm under any of the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system

19.7.2.3.3 Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

Findings:

During fire alarm testing, document review, and interview with Engineer 1 (ES1) on 7/13/17, the written fire procedure for the facility's secured areas were observed, document were reviewed, and staff was interviewed.

At 10:00 a.m., ES1 was interviewed as to what procedures were taken for the facility's secured areas in the event of an emergency. ES1 stated that the secured doors remained locked, and did not release from the magnetic device during the activation of the fire alarm system, and that all staff must use a key to unlock the secured door to exit. There was no other policy and procedure provided for review that indicated that the doors would remain locked unless a key is used to open the secured door. The facility provided a policy that read "Special Procedures for Secured/Sensitive Areas" indicated that the local fire department personnel have keys to all areas of the building located in "Knox Boxes" outside the building by front doors, and backyard exit gate.

Based on document review, and interview, the facility failed to maintain their electrical outlets. This was evidenced by failure to provide the annual tension and polarity test of the electrical outlets. This affected two of two buildings, and could result in the ignition of an electrical fire.

NFPA 99, Health Care Facilities Code, 2012 Edition
6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.
6.3.4.2 Record Keeping.
6.3.4.2.1* General.
6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification.
6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter.

Findings:

During a tour of the facility, document review, and interview with Engineer 1 (ES1) on 7/11/17, the electrical outlets were observed, documents were requested, and staff was interviewed.

At 1:40 p.m., the facility failed to provide the annual testing of the receptacle outlets in the past 12 months. When interviewed, ES1 stated that there was no current receptacle testing, and the previous test was conducted at the end of 2015/beginning of 2016.

Based on observation, and interview, the facility failed to maintain the emergency power supply system (EPSS). This was evidenced by a generator annunciator panel alarm, that was in the OFF position. This affected one of two buildings, and could result in delayed notification to staff in the event of a malfunction of the generator.

NFPA 101, Life Safety Code, 2012 Edition
19.5 Building Services.
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.
9.1.3 Emergency Generators and Standby Power Systems. Where required for compliance with this Code, emergency
generators and standby power systems shall comply with 9.1.3.1 and 9.1.3.2.
9.1.3.1 Emergency generators and standby power systems shall be installed, tested, and maintained in accordance with
NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110, Standard for Emergency and Standby Power Systems, 2010 Edition
5.6.6 Remote Controls and Alarms. A remote, common audible alarm shall be provided as specified in 5.6.5.2(4) that is
powered by the storage battery and located outside of the EPS service room at a work site observable by personnel.
5.6.6.1 An alarm-silencing means shall be provided, and the panel shall include repetitive alarm circuitry so that, after the audible alarm has been silenced, it reactivates after the fault condition has been cleared and has to be restored to its normal position to be silenced again.
5.6.6.2 In lieu of the requirement in 5.6.6.1, a manual alarm silencing means shall be permitted that silences the audible
alarm after the occurrence of the alarm condition, provided such means do not inhibit any subsequent alarms from sounding the audible alarm again without further manual action.

Findings:

During a tour of the facility, and interview with Engineer 1 (ES1) on 7/12/17, the generator annunciator was observed, and staff was interviewed.

At 9:51 a.m., the generator annunciator panel that was located in the Nurse Station on the second floor, had the "ALARM SWITCH" in the "OFF" position. The alarm was silenced. When interviewed, ES1 stated that the alarm was silenced because the monthly load test was being conducted, and staff forgot to switch the alarm back to the "ON" position. The monthly load test was conducted on 7/11/17 at 6:00 a.m. ES1 switched the alarm to the "ON" position at time of survey.

Based on and document review and interview, the facility failed to maintain the emergency power supply system. This was evidenced by failure to exercise once monthly for a minimum of 30 minutes at not less than 30 percent of the EPS nameplate kW rating, and by the failure to complete an annual load bank test for the diesel fueled generator. This could result in the failure of the generator in the event of a power outage. This affected one of two buildings.

NFPA 99, Health Care Facilities Code, 2012 Edition
6.4.1.1.4 Essential electrical systems shall have a minimum of the following two independent sources of power: a normal source generally supplying the entire electrical system and one or more alternate sources for use when the normal source is interrupted.

6.4.1.1.5 Where the normal source consists of generating units on the premises, the alternate source shall be either another generating set or an external utility service.

6.4.4.1.1.3 Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 8.

6.4.4.2 Record Keeping. A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.

NFPA 110, Standard for Emergency and Standby Power Systems, 2010 Edition
8.3.3 A written schedule for routine maintenance and operational testing of the EPSS shall be established.
8.3.4 A permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available.

8.3.8 A fuel quality test shall be performed at least annually using tests approved by ASTM standards.

8.4 Operational Inspection and Testing.

8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.

8.4.2* Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
(2) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating
8.4.2.1 The date and time of day for required testing shall be decided by the owner, based on facility operations.

8.4.2.2 Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.

8.4.2.3 Diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours.

Findings:

During document review, and interview with Engineer 1 (ES1) on 7/11/17, the generator maintenance logs were reviewed, and staff was interviewed.

At 10:45 a.m., the records for the monthly load test for the 125 kilowatt diesel fueled generator were reviewed. The records indicated that nine of twelve months, the facility failed to meet the not less than 30 percent of the EPS nameplate kW rating. There were no records that indicated the facility had completed a supplemental annual load bank test for the 125 kilowatt diesel fueled generator during the past 12 months. The previous annual load bank test was conducted on 2/2/16. When interviewed, ES1 stated that the vendor was scheduled to conduct the annual load bank test in August 2017.

Based on observation, the facility failed to maintain their electrical wiring. This was evidenced by the use of power strips as substitutes for fixed wiring. This affected two of two buildings, and could result in the ignition of an electrical fire.

NFPA 101, Life Safety Code, 2012 Edition
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.
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, National Electrical Code, 2011 Edition
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

Findings

During a tour of the facility with Engineer 1 (ES1) on 7/11/17 to 7/12/17, the electrical wiring and equipment were observed.

Medical Outpatient Building
7/11/17

1. At 9:28 a.m., a microwave and a refrigerator, were plugged into a suspended power strip, in the Conference Room located at Suite B/C/D. The finding was confirmed by ES1.

2. At 9:31 a.m., a coffee machine, refrigerator and a walkie-talkie charger, were plugged into a power strip in the Suite E.

Main Hospital
7/12/17

3. At 9:10 a.m., a hot water machine and a coffee maker, were plugged into a mounted power strip in the Patient Nourishment room located at the Nurse Station on the third floor.

4. At 10:33 a.m., a fan was plugged into a power strip, in the Medical Records Office located in the Health Information Management Office on the first floor. The finding was confirmed by MS1.

5. At 10:34 a.m., a coffee machine, fan and a microwave were plugged into a power strip, in the Doctor's Office located on the first floor.

6. At 10:40 a.m., there were two power strips, plugged into a power strip in the Main Data Room. The finding was confirmed by ES1.