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Based on interview and observation, the facility failed to maintain the building free of penetrations, as evidenced by unsealed pipe conduits and unsealed junction boxes. This condition affected one of four floors in the Main Hospital and one of one floor in the Sotoyome Building and could result in the passage of smoke in the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
8.2.3.2.4.2* Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) *Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following
conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with Engineering Staff between 1/06/14 and 1/09/14, the facility walls and ceilings were observed.

Main Hospital

1. On 1/07/14, at 2:29 p.m. on the 1st floor in Nuclear Med Imaging Room C136, the cover plate for the junction box on the right hand wall was missing.

2. On 1/07/14, at 3:16 p.m. on the Basement Level in the East Basement Server Room 2, cover plates for two junction boxes were missing. There were five quarter-sized penetrations and two one inch penetrations along the righthand wall.
Staff confirmed the unsealed junction boxes and penetrations.

Sotoyome

3. On 1/08/14, at 10:26 a.m. in the Physical Therapy Area, there were nine three to five inch pipe conduits passing through walls that were not sealed.

4. On 1/08/14, at 10:26 a.m. in the Physical Therapy Area, there was one five inch pipe conduit passing through the corridor smoke barrier wall that had not been sealed on the end.

5. On 1/08/14, at 10:40 a.m., in the Home Care Area, there were several three inch to five inch pipe conduits passing through walls that were not sealed on the end. During an interview, Staff confirmed the pipe conduits had not been sealed. Staff stated that the cables passing through the pipe conduits were for the computer systems in use throughout the building.

Based on observation, the facility failed to maintain its corridor doors as evidenced by doors that did not latch when tested. This deficient practice could result in the passage of smoke in the event of a fire and affected three of four floors of the Main Hospital.

NFPA 101 Life Safety Code, 2000 Edition
4.5.7 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained unless the Code exempts such maintenance.

7.2.1.5.4* A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
Exception No. 1:* Egress doors from individual living units and guest rooms of residential occupancies shall be permitted to be provided with devices that require not more than one additional releasing operation, provided that such device is operable from the inside without the use of a key or tool and is mounted at a height not exceeding 48 in. (122 cm) above the finished floor. Existing security devices shall be permitted to have two additional releasing operations. Existing security devices other than automatic latching devices shall not be located more than 60 in. (152 cm) above the finished floor. Automatic latching devices shall not be located more than 48 in. (122 cm) above the finished floor.
Exception No. 2: The minimum mounting height for the releasing mechanism shall not be applicable to existing installations.

Findings:

During a tour of the facility with Engineering Staff Members between 1/06/14 and 1/09/14, the corridor doors were observed.

Main Hospital

1. On 1/08/14, at 9:16 a.m. on the 1st floor in the Emergency Department, the door to the Negative Pressure Room 1 (1112) did not latch when tested. The door stopped at the latch plate in the door frame. The door was equipped with a self-closing device.

2. On 1/08/14, at 9:17 a.m. on the 1st floor in the Emergency Department, the door to the Negative Pressure Room 2 (1110) did not latch when tested. The door stopped at the latch plate in the door frame. The door was equipped with a self-closing device.


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Main Hospital

3. On 1/07/14, at 11:07 a.m. on the 4th floor, the 4 West Storage Room door failed to positively latch when closed.

4. On 1/07/14, at 11:32 a.m. on the 3rd floor, the door to Room LDR7 was held open by a hazardous bin.

5. On 1/07/14, at 11:07 a.m. on the 4th floor, the 4 West Storage Room door failed to positively latch when closed.

Based on observation, the facility failed to maintain the smoke barrier walls as evidenced by an unsealed penetration in a smoke compartment. This condition affected one of four floors in the Main Hospital and could result in the spread of smoke in the event of a fire.

Findings:

During a tour of the facility with a Engineering Staff between 1/06/014 and 1/09/14, the smoke barriers were observed.

Main Hospital

On 1/07/14, at 11:21 a.m. on the 3rd floor above the double doors near the 3 North Waiting Room, a five inch pipe conduit was not sealed on the end. The fire caulking had come off the end of the pipe conduit and exposed a five inch penetration through the smoke barrier wall.

Based on observation and interview, the facility failed to maintain fire doors as evidenced by fire doors that did not fully close and latch, by a fire door that was difficult to open and by a set of fire doors that failed to provide a sealed closure. These deficient conditions affected two of four floors in the Main Hospital and could result in the spread of smoke in the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
8.2.3.2 Fire Protection-Rated Opening Protectives.
8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) *Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

NFPA 80
Standard for Fire Doors and Fire Windows
2-4.1.2* A closing device shall be installed on every fire door. Exception: With approval by the authority having jurisdiction, where pairs of doors are provided for mechanical equipment rooms to allow the movement of equipment, the device shall be permitted to be omitted on the inactive leaf.
2-4.1.3 All components of closing devices used shall be attached securely to doors and frames by steel screws or through-bolts.
2-4.1.4* All closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.


Findings
During a tour of the facility with Engineering Staff between 1/06/14 and 1/07/14, the fire doors were observed.

Main Hospital

1. On 1/09/14, at 10:00 a.m. on the 2nd floor in the Operating Suite, the righthand fire door by Operating Room 7 was difficult to open. When the push hardware was pushed, the door did not open. The push hardware was pushed three times before the latching mechanism released.

2. On 1/09/14, at 11:02 a.m. on the 1st floor by room CE-192, the righthand fire door failed to positively latch when closed.

3. On 1/09/14, at 11:05 a.m. on the 1st floor by Room CE-174, when the fire doors closed and latched, there was a one inch gap between the doors. Air could be felt passing through the doors and the gap was large enough to see through to the other side.

Based on observation, the facility failed to maintain its fire alarm system (FAS) as evidenced by alarm notification devices that failed to function during fire alarm testing. This deficient practice could result in delayed notification and evacuation of patients and staff and affected two of four floors of the Main Hospital.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.4 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 Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.

Findings:

During fire alarm testing with Engineering Staff between 1/06/14 and 1/09/14, the alarm notification devices were observed.

Main Hospital

1. At 9:46 a.m., on the 2nd floor in the Intensive Care Unit by the 2 North Stairwell, the chime/strobe notification device did not emit an audible signal. The chime/strobe notification device did emit a visual signal.

2. At 10:14 a.m., on the 1st floor in the Emergency Department, the chime/strobe notification device did not function. No audible or visual notification signal was emitted.

Based on observation, the facility failed to maintain the manual alarm system as evidenced by a pull station that was obstructed. This condition affected one of four floors in the Main Hospital and could result in delayed access to the pull station on the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
SECTION 9.6 FIRE DETECTION, ALARM, AND
COMMUNICATIONS SYSTEMS
9.6.1.4 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 Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
9.6.1.7* 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 Code.

Findings

During a tour of the facility with a Engineering Staff between 1/06/14 and 1/09/14, the manual pull stations were observed.

Main Hospital

1. On 1/07/14, at 2:34 p.m., on the 1st floor in MRI Imaging, a large blanket warmer was obstructing access to the manual pull station.

Based on observation, the facility failed to maintain the sprinkler heads as evidenced by sprinkler heads covered with layers of dust. This condition affected two of four floors in the Main Hospital and one of one floor at the Sotoyome Building, and it could result in the failure of the sprinklers in the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
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., 1998 edition.
2-2 Inspection.
2.2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
2-3.3* Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.
2-3.3.1* Testing the waterflow alarms on wet pipe systems shall be accomplished by opening the inspectors test connection. Fire pumps shall not be turned off during testing unless all impairment procedures contained in Chapter 11 are followed.
Exception: Where freezing weather conditions or other circumstances prohibit use of the inspector ' s test connection, the bypass connection shall be permitted to be used.

Findings:

During a tour of the facility with Engineering Staff Members between 1/06/14 and 1/09/14, the sprinkler heads were observed.

Main Hospital
1. On 1/07/14, at 11:09 a.m. on the 4th Floor in the 4 West Shower Room by Room W461, the sprinkler head deflector was loaded with a thick layer dust.

2. On 1/07/14, at 2:43 p.m. on the 1st Floor in the Bookshelf Closet in the Cath Lab, the sprinkler head deflector was loaded with a thick layer of dust.


Sotoyome Building
During document review with staff between 1/06/14 and 1/09/14, the documents for the quarterly flow tests were requested.

3. On 1/08/14, at 9:35 a.m., one of four quarterly tests was provided for the past year. The flow test was completed on 12/20/13. There were no flow tests conducted for the 1st, 2nd or 3rd quarters of 2013. During an interview, staff stated that only one quarterly flow test had been completed in the past year.

Based on observation and staff interview, the facility failed to maintain its portable fire extinguishers in the kitchen area as evidenced by fire extinguishers that was mounted higher than 60 inches off the floor and by a fire extinguisher that was not checked monthly. This condition affected one of four floors in the Main Hospital and one of one suite at N. Dutton Ave., and it could result in delayed access to the fire extinguishers in the event of a fire.

NFPA 101 Life Safety Code, 2000 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 installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
NFPA 10 Standard for Portable Fire Extinguishers, 1998 edition
1-6.6 Fire extinguishers shall not be obstructed or obscured from view.
Exception: In large rooms, and in certain locations where visual obstruction cannot be completely avoided, means shall be provided to indicate the location.
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).
4-3.2 Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or "hefting"
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place


Findings:

During a tour of the facility with Engineering Staff between 1/06/14 and 1/09/14, the fire extinguishers were observed.

1. On 1/07/14, at 2:12 p.m. on the 1st floor in the Cafeteria, the K fire extinguisher was mounted approximately 6 feet above the floor in a cabinet over a counter.

2. On 1/07/14, at 2:15 p.m., on the 1st floor in the Kitchen the K fire extinguisher was mounted approximately 6 feet above the floor in a cabinet over a counter.

3. On 1/07/14, at 2:21 p.m., on the 1st floor in the Cafeteria, the ABC fire extinguisher was mounted approximately 6 feet above the floor in a cabinet over a counter.

4. On 1/07/14, at 2:22 p.m., during an interview, staff stated that the fire extinguishers in the Kitchen Area were all mounted over 60 inches above the floor. The cabinets were original components of the building.

N. Dutton Ave.
5. On 1/08/14, at 1:30 p.m., the fire extinguishers in PT at Orthopedic Physical Therapy were not checked on a monthly basis. Staff confirmed that they were not conducting monthly checks of the fire extinguisher.

Based on observation and record review, the facility failed to maintain the kitchen hood fire suppression system as evidenced by failing to conduct the semi-annual service of the fire suppression system. This condition affected one of one floor in the Sotoyome Building and could result in the spread of a fire.

NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 editions
7-2.2 Automatic fire-extinguishing systems shall comply with standard UL 300, Fire Testing of Fire Extinguishing Systems for the protection of Restaurant Cooking Areas, or other equivalent standards and shall be installed in accordance with their listing.

8-2 Inspection - An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.

Table 8-3.1 Exhaust System Inspection Schedule
Systems serving high-volume cooking operations quarterly
(such as 24-hr cooking, charbroiling or wok cooking)
Systems serving moderate-volume cooking semiannually

8-3.1.1 Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person(s) acceptable to the authority having juris-diction in accordance with Section 8-3

Findings:

During a tour of the facility with Engineering Staff between 1/06/14 and 1/09/14, the kitchen hood fire suppression system was observed.

Sotoyome Building
1. On 1/08/14, at 9:33 a.m., the tag for the kitchen hood fire suppression system was dated 7/2008.
During an interview with staff, staff stated that the system had not been serviced in over five years because there was no patient care in the building and the kitchen was not in use. The beds of the Sotoyome Building were in suspense.

Based on document review and interview, the facility failed to test the emergency generator as evidenced by the failure to conducting eleven of twelve monthly full load tests and by not conducting 52 of 52 weekly inspections of the emergency generator. This affected one of one floor of the Sotoyome Building and could result in failure of the generator in the event of a power outage.

NFPA 101, Life Safety Code, 2000 Edition
7.9.2.3 Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems.

9.1.3 Emergency Generators. Emergency generators, where required for compliance with this Code, shall be tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 99, Health Care Facilities, 1999 Edition
3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
(b) Inspection and Testing.
1.* Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
2. Test conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads.
3. Test Personnel. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures.

Findings:

During document review with Engineering Staff on 1/08/14, documents for the generator testing were requested.

Sotoyome
1. At 9:37 a.m., documents provided for the generator full load tests and weekly inspections were reviewed. One of twelve full load tests was completed over the past year and no weekly inspections were conducted. During an interview, staff confirmed that the only test conducted was on 12/20/13.
The beds of the Sotoyome Building were in suspense.

Based on observation, the facility failed to comply with the regulations regarding electrical wiring and utilities. This was evidenced by medical equipment that was plugged into Trip-Lite power strips that were attached to carts in critical patient care areas and anesthetizing locations. This was also evidenced by the improper use of power strips and extension cords in general care and office locations. This deficient practice could lead to an increased risk for an electrical fire and affected four of four floors at the Main Campus and a storage area at Urgent Care Rohnert Park.

NFPA 101, 2000 Edition, Existing 19.3.2 Protection from Hazards. 19.3.2.3 Anesthetizing Locations. Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. 19.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1. 9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.
NFPA 99, 1999 Edition.
2-1-Definitions- Labeled. Equipment or materials to which has been attached a label, symbol, or other identifying mark of an organization that is acceptable to the authority having jurisdiction and concerned with product evaluation, that maintains periodic inspection of production of labeled equipment or materials, and by whose labeling the manufacturer indicates compliance with appropriate standards or performance in a specified manner.
NFPA 99, 1999 Edition.
2-1-Definitions- Listed. Equipment, materials, or services included in a list published by an organization that is acceptable to the authority having jurisdiction and concerned with evaluation of products or services, that maintains periodic inspection of production of listed equipment or materials or periodic evaluation of services, and whose listing states that either the equipment, material, or service meets identified standards or has been tested and found suitable for a specified purpose.

NFPA 99, 19993-3.2.1.2, All patient care areas. (d)(2) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters. NFPA 70, 1999 110-3 Examination, Identification, Installation and use of Equipment
(b) Installation and use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.
NFPA 70, 1999 400.8 Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors.
NFPA 70, 1999
400-10 Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals.

Findings:

Main Hospital (1165 Montgomery Drive):
During a tour of the facility with Engineering Staff between 1/06/14 and 1/09/14, the electrical wiring and equipment were observed.

3rd Floor:
1. On 1/7/14, at 11:36 a.m. on the 3rd floor in the Business Coordinator Office in Women's and Children Services, a microwave oven and refrigerator were plugged into a surge protector.

2. On 1/7/14, at 11:40 a.m. on the 3rd floor in the Sleep Room, a microwave, refrigerator, and fan were plugged into a surge protector.

3. On 1/7/14, at 11:50 a.m. on the 2nd floor in the Employee Lounge North, a blender and coffee grinder were plugged into a brown extension cord.

4. On 1/7/14, at 1:45 p.m. on the 1st floor in the Staffing Office, a water cooler, microwave oven, and refrigerator were plugged into a power strip.

5. On 1/8/14, at 10:08 a.m. on the basement level in the Pharmacy, an orange extension cord was traveling across approximately 8 feet of the wall above storage cabinets to power a surge protector. The surge protector had a computer, monitor, and printer plugged into it.

Urgent Care Rohnert Park (1450 Medical Center Drive, Rohnert Park)
6. On 1/8/14, at 2:15 p.m. in the Laboratory Storage Room, two refrigerators were plugged into a surge protector.


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Main Hospital
7. On 1/07/14, at 11:49 a.m. on the 2nd floor between Rooms A and B of the Pre/Post OP Area, a surge protector was attached to the wall with double-sided tape.

8. On 1/07/14, at 2:40 p.m. on the 1st floor in the Cath Lab Staff Lounge Room 1016, a toaster and a coffee maker were plugged to a surg- protected power strip instead of directly into the wall outlet.

9. On 1/09/14, on the 2nd floor in the Operating Suite, medical equipment was plugged into Trip-Lite power strips. The Trip-Lite power strips were attached to carts with zip ties in operating rooms 1, 5, 7, and 3.
Not all operating rooms were observed due to ongoing procedures. During a staff interview, staff stated the Trip-Lite Power strips were in use in all ten operating rooms.

Based on document review and staff interview, the facility failed to maintain an approved fire watch plan in the event that the automatic sprinkler system was out of service for more than four hours in a twenty-four hour period. This deficient condition affected all building occupants and could result in the lack of staff knowledge of fire watch requirements in the event of a sprinkler system failure.

NFPA 101 Life Safety Code, 2000 edition
9.7.6.1 Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.

Findings:

During document review with staff on 01/09/14, the fire watch plan for the sprinkler system was requested.

At 11:45 a.m., the fire watch plan provided did not include information for a fire watch. The Policy & Procedures provided included information for the Interim Life Safety Measures and stated, "See Fire Watch Policy". No Fire Watch Policy was provided. Staff confirmed that no other policy for the facility fire watch was available.

Based on document review and staff interview, the facility failed to maintain a designated fire watch plan in the event the manual fire system were to fail or be out of service for more than four hours in a twenty-four hour period. This deficient condition affected all building occupants and could result in the lack of staff knowledge of fire watch requirements in the event of a fire alarm system failure.


NFPA 101 Life Safety Code, 2000 edition
9.6.1.8* Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

Findings:

During document review with staff on 01/09/14, the fire watch plan for the manual fire alarm system was requested.

At 11:45 a.m., the fire watch plan provided did not include information for a fire watch. The Policy & Procedures provided included information for the Interim Life Safety Measures and stated, "See Fire Watch Policy." No Fire Watch Policy was provided. Staff confirmed that no other policy for the facility fire watch was available.

Based on observation, the facility failed to prevent its Alcohol Based Hand Rub Dispensers (ABHR) from being installed over or adjacent to ignition sources. This is evidenced by one ABHR dispenser installed over and adjacent to a light switch. This deficient practice could lead to an increased risk for an electrical fire and affected one of four floors at the Main Hospital.

Findings:

During a tour of the facility with Engineering Staff between 1/06/14 and 1/09/14, the ABHR dispensers were observed.

Main Hospital

1. At 9:51 a.m. on the Basement Level in the Respiratory Equipment Room, an ABHR dispenser was installed within approximately 4 inches adjacent to a light switch. The light switch cover plate had splashes of the ABHR liquid on it.

Based on interview and observation, the facility failed to maintain the building free of penetrations, as evidenced by unsealed pipe conduits and unsealed junction boxes. This condition affected one of four floors in the Main Hospital and one of one floor in the Sotoyome Building and could result in the passage of smoke in the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
8.2.3.2.4.2* Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) *Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following
conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with Engineering Staff between 1/06/14 and 1/09/14, the facility walls and ceilings were observed.

Main Hospital

1. On 1/07/14, at 2:29 p.m. on the 1st floor in Nuclear Med Imaging Room C136, the cover plate for the junction box on the right hand wall was missing.

2. On 1/07/14, at 3:16 p.m. on the Basement Level in the East Basement Server Room 2, cover plates for two junction boxes were missing. There were five quarter-sized penetrations and two one inch penetrations along the righthand wall.
Staff confirmed the unsealed junction boxes and penetrations.

Sotoyome

3. On 1/08/14, at 10:26 a.m. in the Physical Therapy Area, there were nine three to five inch pipe conduits passing through walls that were not sealed.

4. On 1/08/14, at 10:26 a.m. in the Physical Therapy Area, there was one five inch pipe conduit passing through the corridor smoke barrier wall that had not been sealed on the end.

5. On 1/08/14, at 10:40 a.m., in the Home Care Area, there were several three inch to five inch pipe conduits passing through walls that were not sealed on the end. During an interview, Staff confirmed the pipe conduits had not been sealed. Staff stated that the cables passing through the pipe conduits were for the computer systems in use throughout the building.

Based on observation, the facility failed to maintain its corridor doors as evidenced by doors that did not latch when tested. This deficient practice could result in the passage of smoke in the event of a fire and affected three of four floors of the Main Hospital.

NFPA 101 Life Safety Code, 2000 Edition
4.5.7 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained unless the Code exempts such maintenance.

7.2.1.5.4* A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
Exception No. 1:* Egress doors from individual living units and guest rooms of residential occupancies shall be permitted to be provided with devices that require not more than one additional releasing operation, provided that such device is operable from the inside without the use of a key or tool and is mounted at a height not exceeding 48 in. (122 cm) above the finished floor. Existing security devices shall be permitted to have two additional releasing operations. Existing security devices other than automatic latching devices shall not be located more than 60 in. (152 cm) above the finished floor. Automatic latching devices shall not be located more than 48 in. (122 cm) above the finished floor.
Exception No. 2: The minimum mounting height for the releasing mechanism shall not be applicable to existing installations.

Findings:

During a tour of the facility with Engineering Staff Members between 1/06/14 and 1/09/14, the corridor doors were observed.

Main Hospital

1. On 1/08/14, at 9:16 a.m. on the 1st floor in the Emergency Department, the door to the Negative Pressure Room 1 (1112) did not latch when tested. The door stopped at the latch plate in the door frame. The door was equipped with a self-closing device.

2. On 1/08/14, at 9:17 a.m. on the 1st floor in the Emergency Department, the door to the Negative Pressure Room 2 (1110) did not latch when tested. The door stopped at the latch plate in the door frame. The door was equipped with a self-closing device.


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3. On 1/07/14, at 11:07 a.m. on the 4th floor, the 4 West Storage Room door failed to positively latch when closed.

4. On 1/07/14, at 11:32 a.m. on the 3rd floor, the door to Room LDR7 was held open by a hazardous bin.

5. On 1/07/14, at 11:07 a.m. on the 4th floor, the 4 West Storage Room door failed to positively latch when closed.

Based on observation, the facility failed to maintain the smoke barrier walls as evidenced by an unsealed penetration in a smoke compartment. This condition affected one of four floors in the Main Hospital and could result in the spread of smoke in the event of a fire.

Findings:

During a tour of the facility with a Engineering Staff between 1/06/014 and 1/09/14, the smoke barriers were observed.

Main Hospital

On 1/07/14, at 11:21 a.m. on the 3rd floor above the double doors near the 3 North Waiting Room, a five inch pipe conduit was not sealed on the end. The fire caulking had come off the end of the pipe conduit and exposed a five inch penetration through the smoke barrier wall.

Based on observation and interview, the facility failed to maintain fire doors as evidenced by fire doors that did not fully close and latch, by a fire door that was difficult to open and by a set of fire doors that failed to provide a sealed closure. These deficient conditions affected two of four floors in the Main Hospital and could result in the spread of smoke in the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
8.2.3.2 Fire Protection-Rated Opening Protectives.
8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) *Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

NFPA 80
Standard for Fire Doors and Fire Windows
2-4.1.2* A closing device shall be installed on every fire door. Exception: With approval by the authority having jurisdiction, where pairs of doors are provided for mechanical equipment rooms to allow the movement of equipment, the device shall be permitted to be omitted on the inactive leaf.
2-4.1.3 All components of closing devices used shall be attached securely to doors and frames by steel screws or through-bolts.
2-4.1.4* All closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.


Findings
During a tour of the facility with Engineering Staff between 1/06/14 and 1/07/14, the fire doors were observed.

Main Hospital

1. On 1/09/14, at 10:00 a.m. on the 2nd floor in the Operating Suite, the righthand fire door by Operating Room 7 was difficult to open. When the push hardware was pushed, the door did not open. The push hardware was pushed three times before the latching mechanism released.

2. On 1/09/14, at 11:02 a.m. on the 1st floor by room CE-192, the righthand fire door failed to positively latch when closed.

3. On 1/09/14, at 11:05 a.m. on the 1st floor by Room CE-174, when the fire doors closed and latched, there was a one inch gap between the doors. Air could be felt passing through the doors and the gap was large enough to see through to the other side.

Based on observation, the facility failed to maintain its fire alarm system (FAS) as evidenced by alarm notification devices that failed to function during fire alarm testing. This deficient practice could result in delayed notification and evacuation of patients and staff and affected two of four floors of the Main Hospital.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.4 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 Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.

Findings:

During fire alarm testing with Engineering Staff between 1/06/14 and 1/09/14, the alarm notification devices were observed.

Main Hospital

1. At 9:46 a.m., on the 2nd floor in the Intensive Care Unit by the 2 North Stairwell, the chime/strobe notification device did not emit an audible signal. The chime/strobe notification device did emit a visual signal.

2. At 10:14 a.m., on the 1st floor in the Emergency Department, the chime/strobe notification device did not function. No audible or visual notification signal was emitted.

Based on observation, the facility failed to maintain the manual alarm system as evidenced by a pull station that was obstructed. This condition affected one of four floors in the Main Hospital and could result in delayed access to the pull station on the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
SECTION 9.6 FIRE DETECTION, ALARM, AND
COMMUNICATIONS SYSTEMS
9.6.1.4 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 Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
9.6.1.7* 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 Code.

Findings

During a tour of the facility with a Engineering Staff between 1/06/14 and 1/09/14, the manual pull stations were observed.

Main Hospital

1. On 1/07/14, at 2:34 p.m., on the 1st floor in MRI Imaging, a large blanket warmer was obstructing access to the manual pull station.

Based on observation, the facility failed to maintain the sprinkler heads as evidenced by sprinkler heads covered with layers of dust. This condition affected two of four floors in the Main Hospital and one of one floor at the Sotoyome Building, and it could result in the failure of the sprinklers in the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
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., 1998 edition.
2-2 Inspection.
2.2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
2-3.3* Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.
2-3.3.1* Testing the waterflow alarms on wet pipe systems shall be accomplished by opening the inspectors test connection. Fire pumps shall not be turned off during testing unless all impairment procedures contained in Chapter 11 are followed.
Exception: Where freezing weather conditions or other circumstances prohibit use of the inspector ' s test connection, the bypass connection shall be permitted to be used.

Findings:

During a tour of the facility with Engineering Staff Members between 1/06/14 and 1/09/14, the sprinkler heads were observed.

Main Hospital
1. On 1/07/14, at 11:09 a.m. on the 4th Floor in the 4 West Shower Room by Room W461, the sprinkler head deflector was loaded with a thick layer dust.

2. On 1/07/14, at 2:43 p.m. on the 1st Floor in the Bookshelf Closet in the Cath Lab, the sprinkler head deflector was loaded with a thick layer of dust.


Sotoyome Building
During document review with staff between 1/06/14 and 1/09/14, the documents for the quarterly flow tests were requested.

3. On 1/08/14, at 9:35 a.m., one of four quarterly tests was provided for the past year. The flow test was completed on 12/20/13. There were no flow tests conducted for the 1st, 2nd or 3rd quarters of 2013. During an interview, staff stated that only one quarterly flow test had been completed in the past year.

Based on observation and staff interview, the facility failed to maintain its portable fire extinguishers in the kitchen area as evidenced by fire extinguishers that was mounted higher than 60 inches off the floor and by a fire extinguisher that was not checked monthly. This condition affected one of four floors in the Main Hospital and one of one suite at N. Dutton Ave., and it could result in delayed access to the fire extinguishers in the event of a fire.

NFPA 101 Life Safety Code, 2000 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 installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
NFPA 10 Standard for Portable Fire Extinguishers, 1998 edition
1-6.6 Fire extinguishers shall not be obstructed or obscured from view.
Exception: In large rooms, and in certain locations where visual obstruction cannot be completely avoided, means shall be provided to indicate the location.
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).
4-3.2 Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or "hefting"
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place


Findings:

During a tour of the facility with Engineering Staff between 1/06/14 and 1/09/14, the fire extinguishers were observed.

1. On 1/07/14, at 2:12 p.m. on the 1st floor in the Cafeteria, the K fire extinguisher was mounted approximately 6 feet above the floor in a cabinet over a counter.

2. On 1/07/14, at 2:15 p.m., on the 1st floor in the Kitchen the K fire extinguisher was mounted approximately 6 feet above the floor in a cabinet over a counter.

3. On 1/07/14, at 2:21 p.m., on the 1st floor in the Cafeteria, the ABC fire extinguisher was mounted approximately 6 feet above the floor in a cabinet over a counter.

4. On 1/07/14, at 2:22 p.m., during an interview, staff stated that the fire extinguishers in the Kitchen Area were all mounted over 60 inches above the floor. The cabinets were original components of the building.

N. Dutton Ave.
5. On 1/08/14, at 1:30 p.m., the fire extinguishers in PT at Orthopedic Physical Therapy were not checked on a monthly basis. Staff confirmed that they were not conducting monthly checks of the fire extinguisher.

Based on observation and record review, the facility failed to maintain the kitchen hood fire suppression system as evidenced by failing to conduct the semi-annual service of the fire suppression system. This condition affected one of one floor in the Sotoyome Building and could result in the spread of a fire.

NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 editions
7-2.2 Automatic fire-extinguishing systems shall comply with standard UL 300, Fire Testing of Fire Extinguishing Systems for the protection of Restaurant Cooking Areas, or other equivalent standards and shall be installed in accordance with their listing.

8-2 Inspection - An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.

Table 8-3.1 Exhaust System Inspection Schedule
Systems serving high-volume cooking operations quarterly
(such as 24-hr cooking, charbroiling or wok cooking)
Systems serving moderate-volume cooking semiannually

8-3.1.1 Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person(s) acceptable to the authority having juris-diction in accordance with Section 8-3

Findings:

During a tour of the facility with Engineering Staff between 1/06/14 and 1/09/14, the kitchen hood fire suppression system was observed.

Sotoyome Building
1. On 1/08/14, at 9:33 a.m., the tag for the kitchen hood fire suppression system was dated 7/2008.
During an interview with staff, staff stated that the system had not been serviced in over five years because there was no patient care in the building and the kitchen was not in use. The beds of the Sotoyome Building were in suspense.

Based on document review and interview, the facility failed to test the emergency generator as evidenced by the failure to conducting eleven of twelve monthly full load tests and by not conducting 52 of 52 weekly inspections of the emergency generator. This affected one of one floor of the Sotoyome Building and could result in failure of the generator in the event of a power outage.

NFPA 101, Life Safety Code, 2000 Edition
7.9.2.3 Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems.

9.1.3 Emergency Generators. Emergency generators, where required for compliance with this Code, shall be tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 99, Health Care Facilities, 1999 Edition
3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
(b) Inspection and Testing.
1.* Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
2. Test conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads.
3. Test Personnel. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures.

Findings:

During document review with Engineering Staff on 1/08/14, documents for the generator testing were requested.

Sotoyome
1. At 9:37 a.m., documents provided for the generator full load tests and weekly inspections were reviewed. One of twelve full load tests was completed over the past year and no weekly inspections were conducted. During an interview, staff confirmed that the only test conducted was on 12/20/13.
The beds of the Sotoyome Building were in suspense.

Based on observation, the facility failed to comply with the regulations regarding electrical wiring and utilities. This was evidenced by medical equipment that was plugged into Trip-Lite power strips that were attached to carts in critical patient care areas and anesthetizing locations. This was also evidenced by the improper use of power strips and extension cords in general care and office locations. This deficient practice could lead to an increased risk for an electrical fire and affected four of four floors at the Main Campus and a storage area at Urgent Care Rohnert Park.

NFPA 101, 2000 Edition, Existing 19.3.2 Protection from Hazards. 19.3.2.3 Anesthetizing Locations. Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. 19.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1. 9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.
NFPA 99, 1999 Edition.
2-1-Definitions- Labeled. Equipment or materials to which has been attached a label, symbol, or other identifying mark of an organization that is acceptable to the authority having jurisdiction and concerned with product evaluation, that maintains periodic inspection of production of labeled equipment or materials, and by whose labeling the manufacturer indicates compliance with appropriate standards or performance in a specified manner.
NFPA 99, 1999 Edition.
2-1-Definitions- Listed. Equipment, materials, or services included in a list published by an organization that is acceptable to the authority having jurisdiction and concerned with evaluation of products or services, that maintains periodic inspection of production of listed equipment or materials or periodic evaluation of services, and whose listing states that either the equipment, material, or service meets identified standards or has been tested and found suitable for a specified purpose.

NFPA 99, 19993-3.2.1.2, All patient care areas. (d)(2) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters. NFPA 70, 1999 110-3 Examination, Identification, Installation and use of Equipment
(b) Installation and use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.
NFPA 70, 1999 400.8 Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors.
NFPA 70, 1999
400-10 Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals.

Findings:

Main Hospital (1165 Montgomery Drive):
During a tour of the facility with Engineering Staff between 1/06/14 and 1/09/14, the electrical wiring and equipment were observed.

3rd Floor:
1. On 1/7/14, at 11:36 a.m. on the 3rd floor in the Business Coordinator Office in Women's and Children Services, a microwave oven and refrigerator were plugged into a surge protector.

2. On 1/7/14, at 11:40 a.m. on the 3rd floor in the Sleep Room, a microwave, refrigerator, and fan were plugged into a surge protector.

3. On 1/7/14, at 11:50 a.m. on the 2nd floor in the Employee Lounge North, a blender and coffee grinder were plugged into a brown extension cord.

4. On 1/7/14, at 1:45 p.m. on the 1st floor in the Staffing Office, a water cooler, microwave oven, and refrigerator were plugged into a power strip.

5. On 1/8/14, at 10:08 a.m. on the basement level in the Pharmacy, an orange extension cord was traveling across approximately 8 feet of the wall above storage cabinets to power a surge protector. The surge protector had a computer, monitor, and printer plugged into it.

Urgent Care Rohnert Park (1450 Medical Center Drive, Rohnert Park)
6. On 1/8/14, at 2:15 p.m. in the Laboratory Storage Room, two refrigerators were plugged into a surge protector.


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7. On 1/07/14, at 11:49 a.m. on the 2nd floor between Rooms A and B of the Pre/Post OP Area, a surge protector was attached to the wall with double-sided tape.

8. On 1/07/14, at 2:40 p.m. on the 1st floor in the Cath Lab Staff Lounge Room 1016, a toaster and a coffee maker were plugged to a surg- protected power strip instead of directly into the wall outlet.

9. On 1/09/14, on the 2nd floor in the Operating Suite, medical equipment was plugged into Trip-Lite power strips. The Trip-Lite power strips were attached to carts with zip ties in operating rooms 1, 5, 7, and 3.
Not all operating rooms were observed due to ongoing procedures. During a staff interview, staff stated the Trip-Lite Power strips were in use in all ten operating rooms.

Based on document review and staff interview, the facility failed to maintain an approved fire watch plan in the event that the automatic sprinkler system was out of service for more than four hours in a twenty-four hour period. This deficient condition affected all building occupants and could result in the lack of staff knowledge of fire watch requirements in the event of a sprinkler system failure.

NFPA 101 Life Safety Code, 2000 edition
9.7.6.1 Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.

Findings:

During document review with staff on 01/09/14, the fire watch plan for the sprinkler system was requested.

At 11:45 a.m., the fire watch plan provided did not include information for a fire watch. The Policy & Procedures provided included information for the Interim Life Safety Measures and stated, "See Fire Watch Policy". No Fire Watch Policy was provided. Staff confirmed that no other policy for the facility fire watch was available.

Based on document review and staff interview, the facility failed to maintain a designated fire watch plan in the event the manual fire system were to fail or be out of service for more than four hours in a twenty-four hour period. This deficient condition affected all building occupants and could result in the lack of staff knowledge of fire watch requirements in the event of a fire alarm system failure.


NFPA 101 Life Safety Code, 2000 edition
9.6.1.8* Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

Findings:

During document review with staff on 01/09/14, the fire watch plan for the manual fire alarm system was requested.

At 11:45 a.m., the fire watch plan provided did not include information for a fire watch. The Policy & Procedures provided included information for the Interim Life Safety Measures and stated, "See Fire Watch Policy." No Fire Watch Policy was provided. Staff confirmed that no other policy for the facility fire watch was available.