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Based upon observations and staff interviews on November 6, 2018 between approximately 0800 an 1800 hours and November 7, 2018 between approximately 0700 and 1300 hours the facility has failed to maintain the fire resistive construction rating of interior walls. This could lead to the rapid spread of fire in areas in which people were seeking shelter.

The findings include:

Two wall penetrations and one ceiling penetration in the basement electrical closet at the 707 N Emerson Street location. Corrected during inspection.

The above was discussed and acknowledged by the with the director of engineering.

Based on observation and staff interview on November 6, 2018 between approximately 0800 an 1800 hours and November 7, 2018 between approximately 0700 and 1300 hours the facility has failed to have appropriate testing of the fire alarm system which result in the failure to notify staff of a problem with the fire alarm system. This could lead to the system not functioning as intended and lead to people within the building not being notified of a fire.

The findings include:

A smoke detector in electrical room B133 had dislodged and was hanging from the ceiling at 820 N Chelan Avenue location.

The above was discussed and acknowledged by the director of engineering.

Based on observation and staff interview on November 6, 2018 between approximately 0800 an 1800 hours and November 7, 2018 between approximately 0700 and 1300 hours the facility has failed to provide fire sprinkler protection to all required areas of the facility. This could result in a fire not being contained to the area of origin and could endanger patients, staff, and/or visitors.

The findings include:

Room 2052 IT closest at the 1201 S Miller Street location did not have fire sprinkler coverage.

The above was discussed and acknowledged by the director of engineering.

Based on observation and staff interview on November 6, 2018 between approximately 0800 an 1800 hours and November 7, 2018 between approximately 0700 and 1300 hours the facility has failed to maintain the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire and allow the fire to increase in size and intensity which would endanger the patients, staff, and/or visitors within the facility.

The findings include:

An escutcheon ring was missing on the fire sprinkler head in urology pre-operative room at the 820 N Chelan Avenue location. Corrected during inspection.

The above was discussed and acknowledged by the director of engineering.

Based on observation and staff interview on November 6, 2018 between approximately 0800 an 1800 hours and November 7, 2018 between approximately 0700 and 1300 hours the facility has failed to maintain doors without impediments to their closing and latching. This could result in a delay in getting the door to the room closed in the event of a fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the patients, staff, and/or visitors within the smoke compartment.

The findings include:

820 N Chelan Avenue location:
Door B136F did not close and latch. Corrected during inspection.
Door 3420 did not close and latch. Corrected during inspection.
Door 3421 was blocked open. Corrected during inspection.

1201 S Miller Street location:
Door 2015 was blocked open. Corrected during inspection.

1215 S Miller Street location:
Door to phlebotomy room was blocked open. Corrected during inspection.

The above was discussed and acknowledged by the director of engineering.

Based on observation and staff interview on November 6, 2018 between approximately 0800 an 1800 hours and November 7, 2018 between approximately 0700 and 1300 hours the facility has failed to maintain electric and gas equipment in a safe manner and in accordance with NFPA 54 and NFPA 70. This could endanger people in the building by risk of fire, electrocution, or other harm.

The findings include:

820 N Chelan Avenue location:
Open junction box with exposed wires in the basement telecom room. Corrected during inspection.
Two open junction boxes with exposed wires in room B132. Corrected during inspection.
Open junction box with exposed wires in room 4549. Corrected during inspection.
Two open junction boxes with exposed wires at the desk located by room 4518. Corrected during inspection.
Open junction box with exposed wires above suspended ceiling inside the main doors of the Bistro. Corrected during inspection.
A cover on an electrical receptacle in the engineering department in the basement. Corrected during inspection.
A cover on an electrical receptacle in the IT department in the basement. Corrected during inspection.
Electrical panel was block by stored items in the basement telecom room. Corrected during inspection.
Electrical panel was block by stored items in room 4534. Corrected during inspection.

707 N Emerson Street location:
Electrical panel was block by stored items in the basement electrical room. Corrected during inspection.

The above was discussed and acknowledged by the director of engineering.

Based on documentation review and staff interview on November 6, 2018 between approximately 0800 an 1800 hours and November 7, 2018 between approximately 0700 and 1300 hours the facility has failed to ensure dampers in the facility were inspected and provided necessary maintenance at least every four years in accordance with NFPA 90A. LSC 9.2.1 requires heating, ventilating and air conditioning (HVAC), ductwork and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems.

NFPA 90A, 2012 Edition, Section 5.4.8.1 states fire dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. NFPA 80, 2010 Edition, Section 19.4.1 states each damper shall be tested and inspected 1 year after installation. The test and inspection frequency shall be every 6 years for hospitals and every 4 years for other occupancies. If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in-place if so equipped. The damper shall not be blocked from closure in any way. All inspections and testing shall be documented, indicating the location of the fire damper, date of inspection, name of inspector and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. This deficient practice could affect all patients, staff, and visitors.

The findings include:

The facility was unable to provide documentation of damper testing at the following locations:

820 N Chelan Avenue
520 N Chelan Avenue
707 N Emerson Street
803 N Emerson Street

The above was discussed and acknowledged by the director of engineering.

Based on documentation review and staff interview on November 6, 2018 between approximately 0800 an 1800 hours and November 7, 2018 between approximately 0700 and 1300 hours the facility failed to properly inspect, test, and maintain the elevators.
The findings include:
The facility was unable to provide documentation of monthly testing of all elevators equipped with fire fighters' emergency operations as required by NFPA 101 section 9.4.6.2 and in accordance with ASME 17.1/CSA B44 at the 820 N Chelan Avenue location.
The above was discussed and acknowledged by the director of engineering.

Based on observation and staff interview on November 6, 2018 between approximately 0800 an 1800 hours and November 7, 2018 between approximately 0700 and 1300 hours the facility has failed to prohibit the use of all space heaters in resident areas and non-approved heaters in staff areas. This could result in a fire due to the ignition of combustible materials that would place patients, staff, and/or visitors in danger.

The findings include:
A non-approved portable heater was in use in room 3459 at 820 N Chelan Avenue locations. Corrected during inspection.

The above was discussed and acknowledged by the director of engineering.

Based on documentation review and staff interview on November 6, 2018 between approximately 0800 an 1800 hours and November 7, 2018 between approximately 0700 and 1300 hours the facility failed to keep records or conduct maintenance on their hospital grade receptacles and non-hospital grade receptacles. This could cause an increased risk of fire due to the non-maintenance of the electrical system.

The findings include:

The facility was unable to provide documentation of periodic testing, which is defined by documented performance data of the hospital grade receptacles at the following locations:
820 N Chelan Avenue
1201 S Miller Street

The facility was unable to provide documentation of annual testing of non-hospital grade receptacles in the vicinity of patient beds and treatment areas at the following locations:
820 N Chelan Avenue
1201 S Miller Street

The above was discussed and acknowledged by the director of engineering.

Based on documentation review and staff interview on November 6, 2018 between approximately 0800 an 1800 hours and November 7, 2018 between approximately 0700 and 1300 hours the facility has failed to maintain and test the emergency generator in accordance with NFPA 110. This could result in a failure of the emergency power system which would leave the facility without egress and task lighting in the event of a power failure which would endanger the patients, staff, and/or visitors within the facility.

The findings include:

The facility was unable to provide documentation of annual generator testing and maintenance for the two generators located at 820 N Chelan Avenue.

The facility does not have a minimum of 96 hours of fuel supply for the Level 1 generator at 820 N Chelan Avenue location.

The above was discussed and acknowledged by the director of engineering.

Based on observation and staff interview on November 6, 2018 between approximately 0800 an 1800 hours and November 7, 2018 between approximately 0700 and 1300 hours the facility failed to restrict the use of extension cords and non-approved power strips in their facility. This could endanger people in the facility due to the increased fire risk.

The findings include:

820 N Chelan Avenue:

A non-UL 1363A or UL 60601-1 powerstrips were observed in use for patient care related electrical equipment in room 4537. Corrected during inspection.

A non-UL 1363A or UL 60601-1 powerstrips were observed in use for patient care related electrical equipment in room 359. Corrected during inspection.

An extension cord was in use as a substitute for fixed wiring in the basement engineering hallway. Corrected during inspection.


1201 S Miller Street:

A non-UL 1363A or UL 60601-1 powerstrips were observed in use for patient care related electrical equipment in room 2006/stress test room 1. Corrected during inspection.

A non-UL 1363A or UL 60601-1 powerstrips were observed in use for patient care related electrical equipment in room 2018. Corrected during inspection.

The above was discussed and acknowledged by the director of engineering.