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Based on document review and interview, the facility failed to develop and implement policies and procedures that support the execution of the emergency plan. This was evidenced by the failure to provide policy and procedure for the use of volunteers that included the process and role for integration of State or Federally designated health care professionals to address surge needs during an emergency. This could result in the failure to protect all patients during a disaster.

Findings:

During document review and interview with staff on 5/15/19, the emergency plan was reviewed.

At 10:47 a.m., the facility failed to provide policy and procedure for the use of volunteers that included the process and role for integration of State or Federally designated health care professionals to address surge needs during an emergency. When interviewed, the RDEM confirmed the finding.

Based on document review and interview, the facility failed to maintain an emergency communication plan. This was evidenced by the failure to include the contact information for staff, physicians, other hospitals and CAHs. This affected all patients, and could result in a delayed response to an emergency situation.

Findings:

During document review and interview with staff on 5/15/19, the emergency communication plan was reviewed.

At 10:55 a.m., the emergency preparedness communication plan did not include the contact information for staff, physicians, other hospitals and CAHs. When interviewed, the RDEM confirmed the finding.

Based on document review and interview, the facility failed to maintain an emergency communication plan. This was evidenced by the failure to update the communication plan. This affected all patients and could result in a delayed response to an emergency situation.

Findings:

During document review and interview with staff on 5/15/19, the emergency communication plan was reviewed.

At 10:59 a.m., the facility failed to update the primary and alternate means for communication in their communication plan. The communication plan indicated that one of the alternate communication was a Satellite phone. When interviewed, the RDEM stated that the facility does not have a Satellite phone but know where to access one in the event of the an emergency. The communication plan did not indicate how the facility would access a Satellite phone.

Based on observation and interview, the facility failed to maintain the means of egress. This was evidenced by an exit that was not continuously maintained free of all obstruction to full use. This affected one of six smoke compartments in the Hospital and could result in delay in evacuation in the event of an emergency.

Findings:

During a tour of the facility with staff on 5/14/19, the means of egress was observed.

At 1:45 p.m., the corridor exit door in the Laboratory was observed. There was a commercial sized electric fan that was placed along the egress pathway at the exit door. The exit door lead to the corridor. The exit was blocked by the electric fan. Staff moved the fan to gain access into the Laboratory. When interviewed, the FM, SE, and AA confirmed the finding.

Based on observation and interview, the facility failed to maintain the fire alarm system components. This was evidenced by alarm notification devices that failed to provide an audible signal and visual. This affected the upper level of the Rural Health Center, and could result in a delay in notification to occupants in the event of a fire.

NFPA 101 Life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6

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.
9.6.3.4 Where permitted by Chapters 11 through 43, a positive alarm sequence shall be permitted, provided that it is in accordance with NFPA 72, National Fire Alarm and Signaling 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
18.2 Purpose. Notification appliances shall provide stimuli for initiating emergency action and provide information to users, emergency response personnel, and occupants.


Findings:

During fire alarm testing and interview with staff on 5/14/19, the fire alarm system were tested.

At 2:40 p.m., the manual pull station located in the upper lobby was tested and the fire alarm system was activated. Two of three chime/strobe alarm devices located in the lobby area did not provide an visual and audible alarm.. When interviewed, the FM, SE, and AA confirmed the finding.

Based on observation, document review, and interview, the facility failed to maintain the fire alarm system. This was evidenced by the failure to provide documentation for the semi-annual fire alarm system inspection and by the failure to reset the fire alarm system. This could lead to a malfunction of the fire alarm system in the event of an emergency. This affected the Hospital and Rural Health Center.

NFPA 101, Life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6

9.6 Fire Detection, Alarm, and Communications 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.


NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition

INSPECTION, TESTING, AND MAINTENANCE, Table 14.3.1

14.3 Inspection.
14.3.1* Unless otherwise permitted by 14.3.2 visual inspections shall be performed in accordance with the schedules in Table 14.3.1 or more often if required by the authority having jurisdiction.

14.6.2.4* A record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 14.6.2.4:
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested
(8) Functional test of detectors
(9)*Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Functional test of mass notification system control units
(13) Functional test of signal transmission to mass notification systems
(14) Functional test of ability of mass notification system to silence fire alarm notification appliances
(15) Tests of intelligibility of mass notification system speakers
(16) Other tests as required by the equipment manufacturer ' s published instructions
(17) Other tests as required by the authority having jurisdiction
(18) Signatures of tester and approved authority representative
(19) Disposition of problems identified during test (e.g., system owner notified, problem corrected/successfully retested, device abandoned in place)


Findings:

During a tour of the facility, document review, and interview with staff on 5/14/19, the fire alarm system document were requested and fire alarm system observed.

Hospital - 15630 18th Avenue, Clearlake

1. At 8:30 a.m., the facility failed to provide documentation for the semi-annual fire alarm system inspection at time of survey. When interviewed, the FM stated that the vendor only test the tamper and waterflow devices during the inspection.

Rural Health Center-15230 Lakeshore Drive, Clearlake

2. At 10:45 a.m., the facility failed to provide documentation for the semi-annual fire alarm system inspection at time of survey. When interviewed, the FM stated that there was no semi-annual inspection conducted at the Rural Health location.

3. Between 2:19 p.m. and 2:31 p.m., the manual pull station in the Breakroom was tested. The pull station could not be reset immediately by staff. Staff key to the pull station did not fit the key hole to reset the pull station. When interviewed, FM stated that the Fire Department was called because they have master keys to pull stations. The FM further stated that the fire alarm system had to be disconnected from power to shut off the alarm.

Based on document review and interview, the facility failed to maintain the fire alarm system. This was evidenced by the failure to provide documentation for smoke detector sensitivity test. This could lead to a malfunction of the fire alarm system in the event of an emergency, and affected the upper and lower level of the Rural Health Center.

NFPA 101, Life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6

9.6 Fire Detection, Alarm, and Communications 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.


NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition

14.4.5.3.1 Sensitivity shall be checked within 1 year after installation.
14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3
14.4.5.3.3 After the second required calibration test, if sensitivity tests indicate that the device has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years.
14.4.5.3.3.1 If the frequency is extended, records of nuisance alarms and subsequent trends of these alarms shall be maintained.
14.4.5.3.3.2 In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
14.4.5.3.4 To ensure that each smoke detector or smoke alarm is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/fire alarm control unit arrangement whereby the detector causes a signal at the fire alarm control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
14.4.5.3.5 Unless otherwise permitted by 14.4.5.3.6, smoke detectors or smoke alarms found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
14.4.5.3.6 Smoke detectors or smoke alarms listed as field adjustable shall be permitted to either be adjusted within the listed and marked sensitivity range, cleaned, and recalibrated, or be replaced.
14.4.5.3.7 The detector or smoke alarm sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector or smoke alarm.


Findings:

During document review and interview with staff on 5/14/19, the document was requested.

At 2:50 p.m., the facility failed to provide smoke detector sensitivity test report upon request. When interviewed, the FM stated that the smoke detectors may be self-reporting and that there are no test report for review. There were no documentation or manual provided that indicated the smoke detectors were self-reporting system.

Based on observation, document review, and interview, the facility failed to maintain the sprinkler system and components. This was evidenced by failure to perform the required test and inspections, by the failure to address deficiencies noted during test and inspections, and by failure to maintain the sprinkler heads. This affected the Hospital and Rural Health Center, and could result in an ineffective operation of the automatic sprinkler system in the event of a fire.

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 Automatic Sprinklers and Other Extinguishing Equipment.
9.7.1 Automatic Sprinklers.
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 Systems, 2011 Edition

Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance
Gauges (dry, preaction deluge systems) Inspection Weekly/monthly 2-2.4.2
Control valves Inspection Weekly/monthly Table 9-1
Alarm devices Inspection Quarterly 2-2.6
Gauges (wet pipe systems) Inspection Monthly 2-2.4.1
Hydraulic nameplate Inspection Quarterly 2-2.7
Buildings Inspection Annually (prior to freezing weather) 2-2.5
Hanger/seismic bracing Inspection Annually 2-2.3
Pipe and fittings Inspection Annually 2-2.2
Sprinklers Inspection Annually 2-2.1.1
Spare sprinklers Inspection Annually 2-2.1.3
Fire department connections Inspection Table 9-1
Valves (all types) Inspection Table 9-1
Alarm devices Test Quarterly 2-3.3
Main drain Test Annually Table 9-1
Antifreeze solution Test Annually 2-3.4
Gauges Test 5 years 2-3.2
Sprinklers - extra-high temp. Test 5 years 2-3.1.1 Exception No. 3
Sprinklers - fast response Test At 20 years and every 10 years thereafter 2-3.1.1 Exception No. 2
Sprinklers Test At 50 years and every 10 years thereafter 2-3.1.1
Valves (all types) Maintenance Annually or as needed Table 9-1
Obstruction investigation Maintenance 5 years or as needed Chapter 10

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 staff, the sprinklers were observed and documents were requested.

Hospital- 15230 Lakeshore Drive, Clearlake (5/13/19)

1. At 3:01 p.m., the facility failed to conduct monthly inspections of the sprinkler gauges and valves. There were no documents provided that indicated the facility conducted monthly inspections. When interviewed, the FM stated that they don't do monthly inspection of gauges and valves and that only quarterly inspections are done.

2. At 3:03 p.m., there was no current five-year certification for the sprinkler system at time of survey. The last five-year certification was performed on 4/16/14. The five year certification for the sprinkler system was over due. When interviewed, the FM stated that they are waiting for vendor to provide them with quote to service the sprinkler system.

Rural Health Center- 15230 Lakeshore Drive, Clearlake (5/14/19)

3. At 9:07 a.m., the quarterly inspection, testing, and maintenance report dated 4/26/19, indicated "missing (1) FDC cap outside by main entrance". There were no documentation provided that the deficiency has been corrected. When interviewed, the SE stated that they are waiting for the vendor to schedule the repair.

4. At 9:30 a.m., the annual inspection, testing, and maintenance report dated 7/24/18, indicated "Deficiency: Piping feeding inspector test valve appears to have been removed for building work. No other means for testing the waterflow alarm device found. Re-pipe old line or install a new line to test wf. This is for the upper pump riser." There were no documentation provided that the deficiency has been corrected. When interviewed, the FM confirmed the finding.

5. At 9:40 a.m., the facility failed to conduct monthly inspections of the sprinkler gauges and valves. There were no documents provided that indicated the facility conducted monthly inspections. When interviewed, the FM confirmed the finding.

6. At 12:50 p.m., the sprinkler in the Provider office had debris around the deflector. The Provider office was near the Nurse Station located in the upper level. This finding was confirmed by , MS, FM, SE, and AA.

7. At 1:02 p.m., one of two sprinkler in the Breakroom had debris around the deflector. The Breakroom was located in the upper level. This finding was confirmed by , MS, FM, SE, and AA.

8. At 1:12 p.m., the sprinkler in the Exam room 1 was missing an escutcheon. This finding was confirmed by , MS, FM, SE, and AA.

9. At 1:50 p.m., the inspector test valve 1 and inspector test valve 2 located in the upper level was not equipped with a reducer. The opening of the valve was approximately 1 1/2 inch diameter. The smallest sprinkler head the facility has was approximately 3/4 inch diameter. This finding was confirmed by MS, FM, SE, and AA.

Based on document review and interview, the facility failed to maintain policy and procedures. This was evidenced by failing to have a written policy on what the facility will do to protect their patients in the event that the automatic sprinkler system is out of service. This could cause staff to not properly respond during an automatic sprinkler system failure, and affected the Hospital and Rural Health Center.

Findings:

During document review and interview with staff on 5/13/19, the policy and procedures for the automatic sprinkler system failure was requested.

At 4:05 p.m., the facility failed to provide a written policy and procedure that describes what the facility will do to protect their patients from fire in the event that the automatic sprinkler system is out of service. When interviewed, the FM and AA confirmed the finding.

Based on observation and interview, the facility failed to maintain the fire extinguishers. This was evidenced by a fire extinguisher that was overcharged and by a fire extinguisher that was obstructed from access. This could result in a delayed notification of malfunctioning portable fire extinguishers, and affected one of six smoke compartments in the Hospital.

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 Extinguisher, 2010 Edition

6.1.3 Placement.
6.1.3.1 Fire extinguishers shall be conspicuously located where they are readily accessible and immediately available in the event of fire.

6.1.3.3 Visual Obstructions.
6.1.3.3.1 Fire extinguishers shall not be obstructed or obscured from view.

Chapter 7 Inspection, Maintenance, and Recharging of Portable Fire Extinguishers
7.1* General.
7.1.1 Responsibility. The owner or designated agent or occupant of a property in which fire extinguishers are located shall be responsible for inspection, maintenance, and recharging. (See 7.1.2.)
7.1.2 Personnel.
7.1.2.1* Persons performing maintenance and recharging of extinguishers shall be certified.
7.1.2.1.1 Persons training to become certified shall be permitted to perform maintenance and recharging of extinguishers under the direct supervision and in the immediate presence of a certified person.
7.1.2.1.2* Certification requires that a person pass a test administered by an organization acceptable to the AHJ.
7.1.2.1.3 The test shall at a minimum be based upon knowledge of the chapters and annexes of this standard.
7.1.2.1.4 The testing process shall permit persons to use the standard during the test.
7.1.2.1.5 Persons passing the test required in 7.1.2.1.2 shall be issued a document or a certificate.
7.1.2.1.6 The document or certificate shall be made available when requested by the authority having jurisdiction.
7.1.2.2 Persons performing maintenance and recharging of extinguishers shall be trained and shall have available the appropriate manufacturer ' s servicing manual(s), the correct tools, recharge materials, lubricants, and manufacturer ' s replacement
parts or parts specifically listed for use in the fire extinguisher.
7.1.2.3* Persons performing 30-day inspections shall not be required to be certified.


Findings:

During a tour of the facility and interview with staff on 5/14/19, the fire extinguishers were observed.

1. At 1:22 p.m., the access to the fire extinguisher in the Lab was obstructed by a Spot Cooler machine. The Spot Cooler was parked directly in front of the fire extinguisher. When interviewed, the SE confirmed the finding.

2. At 3:55 p.m., the needle on the gauge of the fire extinguisher in the Generator location was observed pointed to "Overcharged". The last monthly inspection was conducted on 5/1/19. When interviewed, the FM, SE, and AA confirmed the finding.

Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by corridor doors that failed to latch by a door that was obstructed. This affected three of six smoke compartments in the Hospital, and could result in the inability to contain smoke and/or fire to a room.


Findings:

During a tour of the facility and interview with Staff, the corridor doors were observed.

5/14/19

1. At 1:22 p.m., the door to the Soiled Utility/Biohazard room (334) was equipped with a self-closing device. The door failed to latch when allowed to self-close. When interviewed, the FM, AA, and SE confirmed the finding.

2. At 1:40 p.m., the door to the Shower room 1 was equipped with a self-closing device. The door failed to latch when allowed to self-close. The Shower room was adjacent from Room 314. When interviewed, the FM, AA, and SE confirmed the finding.

3. At 1:42 p.m., the door to the Laboratory was equipped with a self-closing device. The door was held open by a rubber wedge. When interviewed, the FM, AA, and SE confirmed the finding.

5/16/19

4. At 9:12 a.m., the door to the X-ray back entrance was equipped with a self-closing device. The door failed to latch when allowed to self-close. When interviewed, the FM confirmed the finding.

Based on observation and interview, the facility failed to maintain the electrical equipment. This was evidenced by the failure to identify the circuit breaker for the emergency lighting unit in the Operating room, and by circuit breakers that were not legibly identified to specific purpose or use. This affected one of six smoke compartments in the Hospital and the lower level of the Rural Health Center. This could result in staff's inability to identify the circuit breaker in the event of an emergency


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

110.22 Identification of Disconnecting Means.
(A) General. Each disconnecting means shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved. 408.4 Field Identification Required.

(A) Circuit Directory or 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 sufficient detail to allow 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 located at each switch or circuit breaker in a switchboard. No circuit shall be described in a manner that depends on transient conditions of occupancy.


Findings:

During a tour of the facility and interview with staff on 5/14/19, the electrical equipment were observed.

Hospital - 15630 18th Avenue, Clearlake

1. 12:10 p.m., the emergency light unit in Operating room B was observed. When FM was interviewed to how the emergency lighting unit was tested, FM stated that staff would turn off the circuit breaker in electrical Panel P. Upon testing of the emergency lighting unit, staff could not identify which circuit breaker to switch off. Panel P had circuit breaker #1 identified as Room 406 Surgery B. When circuit breaker #1 was switched off, the emergency lighting unit did not activate. Staff was not able to identify which circuit breaker the emergency lighting unit was connected to. When interviewed, FM stated that it would have to be traced by an electrician. This finding was confirmed by FM, SE, and AA.

Rural Health Center-15230 Lakeshore Drive, Clearlake

2. At 1:25 p.m., the electrical panel "PNL CP" in the closet had 24 circuit breakers that were not identified on the directory list provided. The circuit breakers were in the "ON" position. The closet was adjacent from Room 105. When interviewed, the MS stated he was unsure what they are for. This finding was confirmed by the FM, SE, and AA.

3. At 1:33 p.m., the electrical panel "Panel BC" located in the IT room had over 35 circuit breakers that were not identified on the directory list provided. The circuit breakers were in the "ON" position. This finding was confirmed by the FM, SE, and AA.

Based on document review and interview, the facility failed to maintain the heating, ventilation, and air conditioning system (HVAC). This was evidenced by one fire damper that failed during the maintenance of the HVAC system. This affected one of six smoke compartments in the Hospital, and could result in the increased potential for the spread of smoke and fire throughout the facility.


NFPA 101, Life Safety Code, 2012 Edition
19.5.2 Heating, Ventilating, and Air-Conditioning.
19.5.2.1 Heating, ventilating, and air-conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer ' s specifications, unless otherwise modified by 19.5.2.2.

9.2.1 Air-Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air-conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 2012 Edition
5.4.8 Maintenance.
5.4.8.1 Fire dampers and ceiling dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.

NFPA 80, Standard for Fire Doors and Other Opening Protectives, 2010 Edition
19.4* Periodic Inspection and Testing.
19.4.1 Each damper shall be tested and inspected 1 year after installation.
19.4.1.1 The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years.
19.4.3 Full unobstructed access to the fire or combination fire/ smoke damper shall be verified and corrected as required.
19.4.4 If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-inplace if so equipped.
19.4.5 The operational test of the damper shall verify that there is no damper interference due to rusted, bent, misaligned, or damaged frame or blades, or defective hinges or other moving parts.
19.4.6 The damper frame shall not be penetrated by any foreign objects that would affect fire damper operations.
19.4.7 The damper shall not be blocked from closure in any way.
19.4.8 The fusible link shall be reinstalled after testing is complete.
19.4.8.1 If the link is damaged or painted, it shall be replaced with a link of the same size, temperature, and load rating.
19.4.9 All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/ smoke damper, date of inspection, name of inspector, and
deficiencies discovered.
19.4.9.1 The documentation shall have a space to indicate when and how the deficiencies were corrected.
19.4.10 All documentation shall be maintained and made available for review by the AHJ.



Findings:
During document review and interview with staff on 5/13/19, the document was reviewed.

At 1:50 p.m., the document provided titled 2018 FPS Testing Executive Summary indicated that one damper failed on 6/23/17. The report stated "Damper that failed located in non-rated wall (not required), single story fully sprinklered building with rated ceiling assemblies". There were no other documentation provided that repair was made. When interviewed, the FM confirmed the finding and stated that the damper was located in Med Surge unit.

Based on observation and interview, the facility failed to maintain fire safety in the designated smoking area. This was evidenced by cigarette butts being disposed on the ground and by combustible materials disposed inside the safety-type smoke poles. This could result in the increased risk of fire, and affected the Hospital designated smoking area.

Finding:

During a tour of the facility and interview with staff on 5/14/19, the designated smoking area was observed.

At 10:50 a.m., there were over ten dozen cigarette butts observed disposed on the ground in the designated smoking area. There were also mixed garbage disposed with cigarette butts inside the safety-type smoke pole. There was one safety-type smoke pole provided in the designated smoking area. When interviewed, the SE and AA confirmed the finding.

Based on observation and interview, the facility failed to maintain the Oxygen Cylinder Storage Room. This was evidenced by the failure to provide precautionary signage on the door to the piped-in medical gas room. This affected the oxygen storage room located in the Hospital. This could result in the increased risk of fire.


NFPA 99, Health Care Facilities Code, 2012 Edition
5.1.3.1.8 Locations containing positive pressure gases other than oxygen and medical air shall have their door(s) labeled as follows:

Positive Pressure Gases
NO Smoking or Open Flame
Room May Have Insufficient Oxygen
Open Door and Allow Room to
Ventilate Before Entering


Findings:

During a tour of the facility and interview with the SE and AA on 5/14/19, the oxygen cylinder storage room was observed.

At 11:06 a.m., the piped-in medical gas room door was observed. The door was observed without a precautionary sign on the door. The room was observed with oxygen, nitrous oxide gas cylinders, argon compressed cylinders, nitrogen cylinders, and air compressed cylinders. when interviewed, the SE and AA confirmed the finding.

Based on observation and interview, the facility failed to maintain the electrical systems. This was evidenced by the failure to provide safety outlet cover to the receptacle outlet in a patient room. This affected the upper level in the Rural Health Center and could result in the risk of electrical injuries.

Findings:

During a tour of the facility and interview with staff on 5/14/19, the receptacle outlet was observed.

At 12:55 p.m., one of two receptacle outlet in Pediatric Room 54 was not equipped with a safety outlet cover. This finding was confirmed by SE and AA.

Based on document review and interview, the facility failed to maintain electrical receptacles. This was evidenced by failing to have distinct color or marking of their electrical receptacles or cover plates connected to their emergency power supply system (EPSS). This affected one of six smoke compartments in the Hospital. This could potentially potential harm patients if the medical equipment was not using the correct life safety electrical receptacles, in the event of a power failure.

Findings:

During a tour of the facility and interview, with Staff on 5/14/19, the electrical receptacles were observed.

1. At 11:55 a.m., the electrical receptacles or cover plates in Operating room A did not have a distinct coloring or marking. When interviewed, the FM stated that all receptacle outlets in the Operating room were connected to the EPSS.

2. At 11:58 a.m., the electrical receptacles or cover plates in Operating room B did not have a distinct coloring or marking. When interviewed, the FM, SE, and AA confirmed the finding.

Based on observation, document review, and interview, the facility failed to maintain the emergency power supply (EPS). This was evidenced by the failure to perform monthly conductance test on the generator battery, by the failure to provide one set of instruction manual near the equipment, and by the failure to provide complete records of the weekly visual inspections. This affected six of six smoke compartments in the Hospital. This could result in the ineffective operation of the generator in the event of an emergency.


NFPA 101, Life Safety Code, 2012 Edition
19.5.1 Utilities, Utilities shall comply with the provisions of section 9.1
19.5.1.1 Utilities shall comply with the provisions of section 9.1
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.

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

8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted.

8.2* Manuals, Special Tools, and Spare Parts.
8.2.1 At least two sets of instruction manuals for all major components of the EPSS shall be supplied by the manufacturer(s) of the EPSS and shall contain the following:
(1) A detailed explanation of the operation of the system
(2) Instructions for routine maintenance
(3) Detailed instructions for repair of the EPS and other major components of the EPSS
(4) An illustrated parts list and part numbers
(5) Illustrated and schematic drawings of electrical wiring systems, including operating and safety devices, control panels, instrumentation, and annunciators

8.2.2 For Level 1 systems, instruction manuals shall be kept in a secure, convenient location, one set near the equipment, and the other set in a separate location.

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


Findings:

During a tour of the facility, document review, and interview with staff, the EPS location was observed and document reviewed.

5/13/19

1. At 2:10 p.m., the facility failed to perform the monthly conductance test of the batteries for the 750 kW diesel powered generator. The generator was equipped with two 12 volts batteries. When interviewed, the FM stated that the batteries are maintenance free.

2. At 2:35 p.m., the facility did not provide records for 8 of 52 weekly visual inspections for the 750 kW diesel powered generator at time of survey. There were no records provided for September and October of 2018. When interviewed, the AA stated that the inspections were done but unable to locate the records.

5/14/19

3. At 11:10 a.m., there was no instruction manual observed near the generator equipment. When interviewed, the FM stated that the office has a copy of the manual.

Based on observation and interview, the facility failed to maintain electrical safety. This was evidenced by the improper use of power strip and affected the upper level of the Rural Health Center. This could potentially result electrical shock or the ignition of an electrical fire.

NFPA 101, Life Safety Code, 2012 Edition
39.5.1 Utilities. 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 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.
Exception: Listed portable single-pole devices that are intended to accommodate such tension at their terminals shall be permitted to be used with single-conductor flexible cable.


Findings:

During a tour of the facility and interview with staff on 5/14/19, the electrical wiring was observed.

1. At 12:47 p.m., there were laptop and phone charger plugged into a power strip that was suspended approximately 4 feet from the floor. The suspended power strip was observed in the Storage room near the Lobby. This finding was observed by FM, SE, and AA.

Based on document review and interview, the facility failed to maintain their patient care related electrical equipment. This was evidenced by the failure to provide maintenance and testing documentation for the power strip attached to a portable cart in the operating rooms. This could result in electrical equipment malfunction. This affected one of six smoke compartments in the Hospital.

Findings:

During document review and interview with staff on 5/14/19, the patient related electrical equipment documents were reviewed.

At 10:06 a.m., power strip attached to portable carts were observed in the operating rooms. There were no maintenance and testing records provided for the attached power strip at time of survey. When interviewed, the FM stated that this finding was identified during the accrediting organization survey.