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Based on observation, the facility failed to maintain the integrity of their fire barrier walls by providing at least a two-hour fire resistance rated wall. This was evidenced by penetrations in two-hour fire resistance rated walls. This had the potential to allow the spread of smoke and fire from one compartment to another resulting in injury to patients, staff, and visitors. This affected the basement, 2nd and 4th floors of the San Joaquin Community Hospital.

Findings:

During a tour of the facility with the Hospital Staff on September 27, 2011 through September 29, 2011, the fire barrier walls were observed.

San Joaquin Community Hospital at 2615 Chester Avenue
SURVEYOR 27961
1. On 9/27/11 at 2:55 p.m., the fire barrier wall located on the 4th Floor in Tower 1 by Room R4-80 had an approximately 1/2 inch penetration around the pipe where the fire rated material was used but had come loose.

2. On 9/27/11 at 4:00 p.m., the fire barrier wall located on the 2nd Floor in Tower 1 above the smoke barrier doors labeled R2-52 had a penetration measuring approximately 13 inches across x 12 inches wide cut out of both sides of the sheet rock and two penetrations approximately 6 inches x 6 inches on the right side above the drop down ceiling.

3. On 9/28/11 at 9:11 a.m., the fire barrier wall located in the Basement of Tower 1 by the Mail Room had an approximately 1 inch round penetration around one pipe and an approximately 1/2 inch round penetration around the other pipe.

Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by unsealed penetrations in the walls. This could result in faster spread of fire and smoke through compartments causing potential harm to patients and staff in the event of a fire. This affected the basement, 1st floor and 5th floor of the San Joaquin Community Hospital and the Outpatient Services Quest Imaging Center.

Findings:

During a tour of the facility with Hospital Staff On September 27, 2011 through September 29, 2011, the facility walls and ceilings were observed.

San Joaquin Community Hospital at 2615 Chester Avenue
SURVEYOR 27961
1. On 9/27/11 at 2:19 p.m., in the Linen Room on the 5th floor of Tower 1 there was an approximately 1 inch round penetration in the left wall.

2. On 9/28/11 at 9:20 a.m., in the IT Room in the Basement of Tower 1 there were three penetrations approximately 4 inches x 2 inches in the left wall and a 1 inch round penetration around the pipe in the back wall where the red fire rated caulking had come loose.

3. On 9/28/11 at 10:25 a.m., in the Waiting Room for Corrections in the Basement of Tower 2 there was a penetration approximately 2 inches x 2 inches in the right wall behind the blue chairs.

4. On 9/28/11 at 10:35 a.m., in the Histology Room in the Basement of Tower 2 there was a 2 inch x 2 inch penetration in the wall by the refrigerator and an electrical box missing cover plate.

SURVEYOR 29751
5. On 9/28/11 at 9:00 a.m., on the 1st floor of Tower 2, in the ER, the equipment room had two 1/4 inch round unsealed penetrations in the wall behind the entry door.

6. On 9/28/11 at 9:30 a.m., in the old ER of Tower 2, front door of the CDCR, there was a sprinkler with an approximately 3/4 inch gap between the E ring and the ceiling exposing an unsealed penetration.

7. On 9/28/11 at 9:31 a.m., in the old ER, CDCR lobby of Tower 2 there was a one inch unsealed penetration around an electrical conduit going in to the ceiling.

8. On 9/28/11 at 10:00 a.m., on the 1st floor of Tower 2 in the CATH lab, 1 of 4 sprinklers had an unsealed penetration and cracked plaster around the E ring which was hanging 2 1/2 inches down from ceiling.

Outpatient Services - Quest Imaging at 9602 Stockdale Avenue
SURVEYOR 29751
9. On 9/28/11 at 1:46 p.m., in the crawl space near the exit lobby, there were two junction boxes placed inside the smoke barrier wall creating unsealed penetrations.

Based on observation, the facility failed to maintain the doors as evidenced by corridor doors that failed to positive latch and/or were blocked from closing. This would allow smoke and fire to travel throughout the facility and increase the risk of harm to the patients, staff and visitors in the event of a fire. This affected basement and 5th floor of the San Joaquin Community Hospital.

Findings:

During a tour of the facility with the Hospital Staff on September 27, 2011 through September 29, 2011, the facilities corridor doors were observed.

San Joaquin Community Hospital at 2615 Chester Avenue
SURVEYOR 27961
1. On 9/27/11 at 2:22 p.m., the door to Room 5121 on the 5th Floor of Tower 1 failed to latch when manually closed.

2. On 9/27/11 at 2:30 p.m., the door to Room R5-86 next to the Med Room was equipped with a self closing device. The door was held open to the fullest extent and allowed to close but, failed to positive latch upon closure.

3. On 9/28/11 at 9:56 a.m., the door to the Laundry Room in the Basement of Tower 2 was equipped with a self closing device. The door was held open to the fullest extent and allowed to close but, failed to positive latch upon closure.

SURVEYOR 29751
4. At 9:55 a.m., in the CATH Lab recovery area of Tower 2, the fire door on a closing device had a white trash can propped against the door impeding its ability to close if an alarm was activated.

Based on observation, the facility failed to maintain their smoke barrier doors as evidenced by smoke barrier door that failed to fully close and positive latch upon closure. This finding could result in the spread of smoke and fire from one smoke compartment to the adjacent smoke compartment and increase the risk of injury to residents and staff. This affected the 4th floor of the San Joaquin Community Hospital and Outpatient Services - Quest Imaging.

Findings:

During fire alarm testing with the Hospital Staff on September 27, 2011 through September 29, 2011, the smoke barrier doors were tested and observed.

San Joaquin Community Hospital at 2615 Chester Avenue
SURVEYOR 27961
1. On 9/28/11 at 3:23 p.m., smoke barrier double doors 4116 on the 4th floor failed to positive latch on the right side after activation of a pull station.

2. On 9/28/11 at 3:23 p.m., the smoke barrier double doors to the Staff Lounge failed to positive latch on the right side after activation of a pull station.

Outpatient Services - Quest Imaging at 9602 Stockdale Avenue
SURVEYOR 29751
3. On 9/28/11 at 2:05 p.m., the automatic closing doors in the registration area did not release from the magnet during alarm testing.

Based on observation, the facility failed to maintain the doors in stairways used as exits as evidenced by stairwell doors that failed to positively latch. This had the potential for fire and smoke to spread, rendering the stairway non-usable for patients, staff, and visitors. This affected the 3rd floor of the San Joaquin Community Hospital.

Findings:

During a tour of the facility with the Hospital Staff on September 27, 2011 through September 29, 2011, the stairwell egresses were observed.

San Joaquin Community Hospital at 2615 Chester Avenue
SURVEYOR 27961
1. On 9/27/11, at 3:40 p.m., the latching mechanism to the door in Stairwell R3-68A located on the 3rd Floor in Tower 1 failed to positively latch due to a blue scrub hair net stuffed into the strike plate.

Based on observation and interview, the facility failed to maintain their emergency lighting. This was evidenced by emergency lighting units that failed to illuminate when tested. This had the potential for delaying evacuation and causing injury to patients, staff, and visitors. This affected the generator rooms outside at San Joaquin Community Hospital.

Findings:

During a tour of the facility with the Hospital Staff on September 27, 2011 through September 29, 2011, the emergency lighting was observed and tested.

San Joaquin Community Hospital at 2615 Chester Avenue
SURVEYOR 27961
1. On 9/28/11 at 10:45 a.m., the emergency lighting in the generator room for Tower 1 failed to illuminate when tested. When interviewed on 9/28/11 at 10:45 a.m., the Director, Construction Services stated that they will add the emergency lighting in the generator rooms to the preventative maintenance logs for testing every month.

2. On 9/28/11 at 10:47 a.m., the emergency lighting in the generator room for Tower 2 failed to illuminate when tested. When interviewed on 9/28/11 at 10:45 a.m., the Director, Construction Services stated that they will add these emergency lighting in the generator rooms to the preventative maintenance logs for testing every month.

NFPA 101, Life Safety Code, 2000 Edition
9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.
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.
9.6.3.9 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building.

Based on document review, observation and testing, the facility failed to provide effective warning of fire as evidenced by an area where the strobes could not be heard in the Outpatient Services - Quest Imaging Center, and, the facility failed to maintain the fire alarm system at the Outpatient Services - Cardiac Rehab and Wellness Center as evidenced by the monitoring company not identifying what type of signal was received, too many signals received and an incorrect address on the report. This could result in delay in notifying patients, visitors and staff of a fire in the facility, causing potential injury.

During a tour of the facility with the Hospital Staff on September 27, 2011 through September 29, 2011, the strobes and chimes were observed and tested and the monitoring company's report was reviewed.

Outpatient Services - Quest Imaging at 9602 Stockdale Avenue
SURVEYOR 27961
1. On 9/28/11 at 2:03 p.m., the fire alarm notification devices were activated and the alarms were not heard by the surveyor or staff in the Mammogram/Ultrasound area in the Women's Center. When interviewed on September 28, 2011 at 2:03 p.m., Hospital Staff was asked if they could hear the alarms and they stated that they could not.

Outpatient Services - Cardiac Rehab & Wellness Center at 1524 27th Street
SURVEYOR 27961
2. On 9/29/11 at 10:30 a.m., the Activity Report from Tel-Tec Security Systems, Inc. indicated that the center was mapped to an address of the report of 1525 28th Street and not to the physical location of 1524 27th Street. When interviewed on 9/29/11 at 10:30 a.m., the Director, Construction Services stated that this was the report for the Cardiac Rehab & Wellness Center.

3. On 9/29/11 at 10:33 a.m., the Activity Report from Tel-Tec Security Systems, Inc. reported 7 more signals received than actually tested at the facility that day.

NFPA 72, National Fire Alarm Code, 1999 Edition.
Table 7-3.2 Testing Frequencies.
6. Batteries -- Fire Alarm Systems
d. Sealed Lead-Acid Type,
1. Charger Test (Replace battery every 4 years.)
Based on observation and interview, the facility failed to maintain their fire alarm system as evidenced by batteries in the fire alarm panel that were past the replacement date. This could cause harm to patients and staff in the event of a fire. This affected the basement at San Joaquin Community Hospital.

Findings:

During a tour of the facility with the Hospital Staff on September 27, 2011 through September 29, 2011, the batteries in the fire alarm panels were observed.

San Joaquin Community Hospital at 2615 Chester Avenue
Surveyor 27961
1. At 10:00 a.m., in the Basement of Tower 2, two batteries in the main fire alarm panel and two batteries in the booster panel were dated 1/3/07. When interviewed on September 28, 2011 at 10:01 a.m., the Director, Construction Services was asked if they had the manufacturer specifications for the battery in the fire alarm panel. The Director stated that they did not have the paperwork.

NFPA 101, Life Safety Code, 2000 Edition
19.3.5 Extinguishment Requirements.
19.3.5.3* Where this Code permits exceptions for fully sprinklered buildings or smoke compartments and specifically references this paragraph, the sprinkler system shall meet the following criteria:
(1) It shall be installed throughout the building in accordance with Section 9.7.
(2) It shall be electrically connected to the fire alarm system.
(3) It shall be fully supervised.
(4) It shall be equipped with listed quick-response or listed residential sprinklers throughout all smoke compartments containing patient sleeping rooms.
Exception No. 1: Standard response sprinklers shall be permitted to be continued to be used in existing approved sprinkler systems where quick-response and residential sprinklers were not listed for use in such locations at the time of installation.

9.7.1 Automatic Sprinklers.
9.7.2.1* Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.
9.7.2.2 Alarm Signal Transmission. Where supervision of automatic sprinkler systems is provided in accordance with another provision of this Code, water flow alarms shall be transmitted to an approved, proprietary alarm receiving facility, a remote station, a central station, or the fire department. Such connection shall be in accordance with 9.6.1.4.

Based on document review and testing, the facility failed to maintain their Automatic Sprinkler System as evidenced by no Tamper installed at the Cardiac Rehab & Wellness Center location and, therefore, no transmission to the monitoring company and, by the monitoring company not receiving the Water flow/Inspector Test Valve (ITV) alarm that was tested at the San Joaquin Community Hospital location and, by an obstruction to the 18" sprinkler clearance. This could cause harm to patients and staff in the event of a fire and affected the entire building.

Findings:

On a facility tour and testing and document review with the Hospital Staff on September 27, 2011 through September 29, 2011, the alarm activation devices were observed and tested and documentation reviewed.

Outpatient Services - Cardiac Rehab & Wellness Center at 1524 27th St.
Surveyor 27961
1. On 9/28/11 at 11:40 a.m., the Tamper could not be tested because the facility did not have one according to the Director, Construction Services.

SURVEYOR 29751
2. On 9/28/11 at 11:44 a.m., during water flow test, the outside alarm did not ring when the inside alarms were activated. This test was conducted twice and failed twice. Hospital staff confirmed the malfunction of the outside alarm during testing.


San Joaquin Community Hospital at 2615 Chester Avenue
SURVEYOR 27961
2. On 9/29/11 at 10:34 a.m., the paperwork from the monitoring company failed to indicate that the Water flow or Tamper had transmitted a signal to the monitoring company.

SURVEYOR 29751
3. On 9/28/11 at 2:30 p.m., on the 5th floor of Tower 2, in the house keeping closet Room 5-107 there was a sprinkler spray pattern obstructed by a 32 inch fluorescent light bulb.

Based on observation, the facility failed to maintain their automatic sprinkler system as evidenced by sprinklers that were not free of dust/debris. These findings could result in the fire sprinkler system not functioning as designed and increased risk of injury to patients and staff. This affected the Pre-Op area in Tower 1 of San Joaquin Community Hospital.

Findings:

During a tour of the facility with the Hospital Staff on September 27, 2011 through September 29, 2011, the sprinkler system was observed.

San Joaquin Community Hospital at 2615 Chester Avenue
SURVEYOR 27961
1. On 9/27/11 at 4:31 p.m., in Pre-Op area in Tower 1 there were 10 sprinklers covered in dust/debris.

Based on observation, the facility failed to maintain their fire extinguishers as evidenced the failure to mount the extinguishers according to NFPA 10, 1998 Edition. This could result in a delayed response to a fire and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected the 1st floor, Tower 2 of San Joaquin Community Hospital.

Findings:

During a tour of the facility with maintenance on September 28, 2011, the fire extinguishers were observed.

San Joaquin Community Hospital at 2615 Chester Avenue
SURVEYOR 29751
1. At 10:15 a.m., the 1st Floor MRI area in the doctor's lounge on Tower 2, there was a sign posted on the wall to the left of the entry indicating a fire extinguisher was mounted below. After observation of the area it was determined that there was no fire extinguisher under the sign or in the area of the sign. The absence of the fire extinguisher was confirmed by hospital staff touring the facility during survey.

NFPA 99 Health Care Facilities, 1999 Edition
4-3.1.1.1. Cylinder and Container Management. Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

Based on observation, the facility failed to ensure that the oxygen cylinders were properly secured as evidenced by unsecured oxygen tanks. This could cause harm to patients and staff in the event the cylinder fell on something or someone and/or the high pressure valve was damaged and caused the cylinder to move about in an uncontrolled manner. This affected the outside oxygen storage area at San Joaquin Community Hospital.

Findings:

During a tour of the facility with the Hospital Staff on September 27, 2011 through September 29, 2011, the facilities oxygen storage areas and tanks were observed.

San Joaquin Community Hospital at 2615 Chester Avenue
SURVEYOR 27961
1. On 9/28/11 at 10:50 a.m., there was a chain link fenced in area approximately 10 feet x 8 feet outside the facility that contained 54 H-Oxygen tanks which were secured with one chain across the front of them (picture attached).

NFPA 70 Section 400-8 1999 Ed. Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for a 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
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

Based on observation, the facility failed to maintain their electrical safety. This was evidenced by the use of multi outlet adapters, use of an extension cord, and broken ground ports. This could result in an increased risk of electrical fire and potential injury to residents and staff. This affected the 3rd floor and the 4th floor of San Joaquin Community Hospital.

Findings:

During a tour of the facility with the Hospital Staff on September 27, 2011 through September 29, 2011, the electrical system was observed.

San Joaquin Community Hospital at 2615 Chester Avenue
SURVEYOR 27961
1. On 9/27/11 at 3:15 p.m., in Equipment Room R3-4 on the 3rd floor in Tower 1 there was a microwave plugged into an extension cord and not directly into the electrical outlet in the wall.

SURVEYOR 29751
2. On 9/28/11 at 3:05 p.m., on the 4th Floor in Room 4214 of Tower 2, adjacent to Bed B, there was a broken faceplate cover on an electrical outlet exposing the interior of the wall.

3. On 9/28/11 at 3:09 p.m., on the 4th Floor in Room 4208 of Tower 2, adjacent to the restroom, there was an electrical outlet missing faceplate cover.

4. On 9/28/11 at 3:15 p.m., on the 4th floor in the Nursing Supervisors office of Tower 2, there was a refrigerator plugged into a surge protector.

Based on observation, the facility failed to ensure an Alcohol Based Hand Rub (ABHR) dispenser was installed away from ignition sources as evidenced by an ABHR mounted adjacent to a light switch. This could result in a fire and increase the risk of injury to patients, visitors and staff. This affected Outpatient Services - Quest Imaging.

Findings:

During a tour of the facility with the Hospital Staff on September 27, 2011 through September 29, 2011, the ABHR dispensers were observed.

Outpatient Services - Quest Imaging at 9602 Stockdale Avenue
SURVEYOR 29751
1. At 1:35 p.m., in the employee lounge there was one ABHR adjacent to a light switch.

Based on observation, the facility failed to maintain the integrity of their fire barrier walls by providing at least a two-hour fire resistance rated wall. This was evidenced by penetrations in two-hour fire resistance rated walls. This had the potential to allow the spread of smoke and fire from one compartment to another resulting in injury to patients, staff, and visitors. This affected the basement, 2nd and 4th floors of the San Joaquin Community Hospital.

Findings:

During a tour of the facility with the Hospital Staff on September 27, 2011 through September 29, 2011, the fire barrier walls were observed.

San Joaquin Community Hospital at 2615 Chester Avenue
SURVEYOR 27961
1. On 9/27/11 at 2:55 p.m., the fire barrier wall located on the 4th Floor in Tower 1 by Room R4-80 had an approximately 1/2 inch penetration around the pipe where the fire rated material was used but had come loose.

2. On 9/27/11 at 4:00 p.m., the fire barrier wall located on the 2nd Floor in Tower 1 above the smoke barrier doors labeled R2-52 had a penetration measuring approximately 13 inches across x 12 inches wide cut out of both sides of the sheet rock and two penetrations approximately 6 inches x 6 inches on the right side above the drop down ceiling.

3. On 9/28/11 at 9:11 a.m., the fire barrier wall located in the Basement of Tower 1 by the Mail Room had an approximately 1 inch round penetration around one pipe and an approximately 1/2 inch round penetration around the other pipe.

Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by unsealed penetrations in the walls. This could result in faster spread of fire and smoke through compartments causing potential harm to patients and staff in the event of a fire. This affected the basement, 1st floor and 5th floor of the San Joaquin Community Hospital and the Outpatient Services Quest Imaging Center.

Findings:

During a tour of the facility with Hospital Staff On September 27, 2011 through September 29, 2011, the facility walls and ceilings were observed.

San Joaquin Community Hospital at 2615 Chester Avenue
SURVEYOR 27961
1. On 9/27/11 at 2:19 p.m., in the Linen Room on the 5th floor of Tower 1 there was an approximately 1 inch round penetration in the left wall.

2. On 9/28/11 at 9:20 a.m., in the IT Room in the Basement of Tower 1 there were three penetrations approximately 4 inches x 2 inches in the left wall and a 1 inch round penetration around the pipe in the back wall where the red fire rated caulking had come loose.

3. On 9/28/11 at 10:25 a.m., in the Waiting Room for Corrections in the Basement of Tower 2 there was a penetration approximately 2 inches x 2 inches in the right wall behind the blue chairs.

4. On 9/28/11 at 10:35 a.m., in the Histology Room in the Basement of Tower 2 there was a 2 inch x 2 inch penetration in the wall by the refrigerator and an electrical box missing cover plate.

SURVEYOR 29751
5. On 9/28/11 at 9:00 a.m., on the 1st floor of Tower 2, in the ER, the equipment room had two 1/4 inch round unsealed penetrations in the wall behind the entry door.

6. On 9/28/11 at 9:30 a.m., in the old ER of Tower 2, front door of the CDCR, there was a sprinkler with an approximately 3/4 inch gap between the E ring and the ceiling exposing an unsealed penetration.

7. On 9/28/11 at 9:31 a.m., in the old ER, CDCR lobby of Tower 2 there was a one inch unsealed penetration around an electrical conduit going in to the ceiling.

8. On 9/28/11 at 10:00 a.m., on the 1st floor of Tower 2 in the CATH lab, 1 of 4 sprinklers had an unsealed penetration and cracked plaster around the E ring which was hanging 2 1/2 inches down from ceiling.

Outpatient Services - Quest Imaging at 9602 Stockdale Avenue
SURVEYOR 29751
9. On 9/28/11 at 1:46 p.m., in the crawl space near the exit lobby, there were two junction boxes placed inside the smoke barrier wall creating unsealed penetrations.

Based on observation, the facility failed to maintain the doors as evidenced by corridor doors that failed to positive latch and/or were blocked from closing. This would allow smoke and fire to travel throughout the facility and increase the risk of harm to the patients, staff and visitors in the event of a fire. This affected basement and 5th floor of the San Joaquin Community Hospital.

Findings:

During a tour of the facility with the Hospital Staff on September 27, 2011 through September 29, 2011, the facilities corridor doors were observed.

San Joaquin Community Hospital at 2615 Chester Avenue
SURVEYOR 27961
1. On 9/27/11 at 2:22 p.m., the door to Room 5121 on the 5th Floor of Tower 1 failed to latch when manually closed.

2. On 9/27/11 at 2:30 p.m., the door to Room R5-86 next to the Med Room was equipped with a self closing device. The door was held open to the fullest extent and allowed to close but, failed to positive latch upon closure.

3. On 9/28/11 at 9:56 a.m., the door to the Laundry Room in the Basement of Tower 2 was equipped with a self closing device. The door was held open to the fullest extent and allowed to close but, failed to positive latch upon closure.

SURVEYOR 29751
4. At 9:55 a.m., in the CATH Lab recovery area of Tower 2, the fire door on a closing device had a white trash can propped against the door impeding its ability to close if an alarm was activated.

Based on observation, the facility failed to maintain their smoke barrier doors as evidenced by smoke barrier door that failed to fully close and positive latch upon closure. This finding could result in the spread of smoke and fire from one smoke compartment to the adjacent smoke compartment and increase the risk of injury to residents and staff. This affected the 4th floor of the San Joaquin Community Hospital and Outpatient Services - Quest Imaging.

Findings:

During fire alarm testing with the Hospital Staff on September 27, 2011 through September 29, 2011, the smoke barrier doors were tested and observed.

San Joaquin Community Hospital at 2615 Chester Avenue
SURVEYOR 27961
1. On 9/28/11 at 3:23 p.m., smoke barrier double doors 4116 on the 4th floor failed to positive latch on the right side after activation of a pull station.

2. On 9/28/11 at 3:23 p.m., the smoke barrier double doors to the Staff Lounge failed to positive latch on the right side after activation of a pull station.

Outpatient Services - Quest Imaging at 9602 Stockdale Avenue
SURVEYOR 29751
3. On 9/28/11 at 2:05 p.m., the automatic closing doors in the registration area did not release from the magnet during alarm testing.

Based on observation, the facility failed to maintain the doors in stairways used as exits as evidenced by stairwell doors that failed to positively latch. This had the potential for fire and smoke to spread, rendering the stairway non-usable for patients, staff, and visitors. This affected the 3rd floor of the San Joaquin Community Hospital.

Findings:

During a tour of the facility with the Hospital Staff on September 27, 2011 through September 29, 2011, the stairwell egresses were observed.

San Joaquin Community Hospital at 2615 Chester Avenue
SURVEYOR 27961
1. On 9/27/11, at 3:40 p.m., the latching mechanism to the door in Stairwell R3-68A located on the 3rd Floor in Tower 1 failed to positively latch due to a blue scrub hair net stuffed into the strike plate.

Based on observation and interview, the facility failed to maintain their emergency lighting. This was evidenced by emergency lighting units that failed to illuminate when tested. This had the potential for delaying evacuation and causing injury to patients, staff, and visitors. This affected the generator rooms outside at San Joaquin Community Hospital.

Findings:

During a tour of the facility with the Hospital Staff on September 27, 2011 through September 29, 2011, the emergency lighting was observed and tested.

San Joaquin Community Hospital at 2615 Chester Avenue
SURVEYOR 27961
1. On 9/28/11 at 10:45 a.m., the emergency lighting in the generator room for Tower 1 failed to illuminate when tested. When interviewed on 9/28/11 at 10:45 a.m., the Director, Construction Services stated that they will add the emergency lighting in the generator rooms to the preventative maintenance logs for testing every month.

2. On 9/28/11 at 10:47 a.m., the emergency lighting in the generator room for Tower 2 failed to illuminate when tested. When interviewed on 9/28/11 at 10:45 a.m., the Director, Construction Services stated that they will add these emergency lighting in the generator rooms to the preventative maintenance logs for testing every month.

NFPA 101, Life Safety Code, 2000 Edition
9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.
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.
9.6.3.9 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building.

Based on document review, observation and testing, the facility failed to provide effective warning of fire as evidenced by an area where the strobes could not be heard in the Outpatient Services - Quest Imaging Center, and, the facility failed to maintain the fire alarm system at the Outpatient Services - Cardiac Rehab and Wellness Center as evidenced by the monitoring company not identifying what type of signal was received, too many signals received and an incorrect address on the report. This could result in delay in notifying patients, visitors and staff of a fire in the facility, causing potential injury.

During a tour of the facility with the Hospital Staff on September 27, 2011 through September 29, 2011, the strobes and chimes were observed and tested and the monitoring company's report was reviewed.

Outpatient Services - Quest Imaging at 9602 Stockdale Avenue
SURVEYOR 27961
1. On 9/28/11 at 2:03 p.m., the fire alarm notification devices were activated and the alarms were not heard by the surveyor or staff in the Mammogram/Ultrasound area in the Women's Center. When interviewed on September 28, 2011 at 2:03 p.m., Hospital Staff was asked if they could hear the alarms and they stated that they could not.

Outpatient Services - Cardiac Rehab & Wellness Center at 1524 27th Street
SURVEYOR 27961
2. On 9/29/11 at 10:30 a.m., the Activity Report from Tel-Tec Security Systems, Inc. indicated that the center was mapped to an address of the report of 1525 28th Street and not to the physical location of 1524 27th Street. When interviewed on 9/29/11 at 10:30 a.m., the Director, Construction Services stated that this was the report for the Cardiac Rehab & Wellness Center.

3. On 9/29/11 at 10:33 a.m., the Activity Report from Tel-Tec Security Systems, Inc. reported 7 more signals received than actually tested at the facility that day.

NFPA 72, National Fire Alarm Code, 1999 Edition.
Table 7-3.2 Testing Frequencies.
6. Batteries -- Fire Alarm Systems
d. Sealed Lead-Acid Type,
1. Charger Test (Replace battery every 4 years.)
Based on observation and interview, the facility failed to maintain their fire alarm system as evidenced by batteries in the fire alarm panel that were past the replacement date. This could cause harm to patients and staff in the event of a fire. This affected the basement at San Joaquin Community Hospital.

Findings:

During a tour of the facility with the Hospital Staff on September 27, 2011 through September 29, 2011, the batteries in the fire alarm panels were observed.

San Joaquin Community Hospital at 2615 Chester Avenue
Surveyor 27961
1. At 10:00 a.m., in the Basement of Tower 2, two batteries in the main fire alarm panel and two batteries in the booster panel were dated 1/3/07. When interviewed on September 28, 2011 at 10:01 a.m., the Director, Construction Services was asked if they had the manufacturer specifications for the battery in the fire alarm panel. The Director stated that they did not have the paperwork.

NFPA 101, Life Safety Code, 2000 Edition
19.3.5 Extinguishment Requirements.
19.3.5.3* Where this Code permits exceptions for fully sprinklered buildings or smoke compartments and specifically references this paragraph, the sprinkler system shall meet the following criteria:
(1) It shall be installed throughout the building in accordance with Section 9.7.
(2) It shall be electrically connected to the fire alarm system.
(3) It shall be fully supervised.
(4) It shall be equipped with listed quick-response or listed residential sprinklers throughout all smoke compartments containing patient sleeping rooms.
Exception No. 1: Standard response sprinklers shall be permitted to be continued to be used in existing approved sprinkler systems where quick-response and residential sprinklers were not listed for use in such locations at the time of installation.

9.7.1 Automatic Sprinklers.
9.7.2.1* Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.
9.7.2.2 Alarm Signal Transmission. Where supervision of automatic sprinkler systems is provided in accordance with another provision of this Code, water flow alarms shall be transmitted to an approved, proprietary alarm receiving facility, a remote station, a central station, or the fire department. Such connection shall be in accordance with 9.6.1.4.

Based on document review and testing, the facility failed to maintain their Automatic Sprinkler System as evidenced by no Tamper installed at the Cardiac Rehab & Wellness Center location and, therefore, no transmission to the monitoring company and, by the monitoring company not receiving the Water flow/Inspector Test Valve (ITV) alarm that was tested at the San Joaquin Community Hospital location and, by an obstruction to the 18" sprinkler clearance. This could cause harm to patients and staff in the event of a fire and affected the entire building.

Findings:

On a facility tour and testing and document review with the Hospital Staff on September 27, 2011 through September 29, 2011, the alarm activation devices were observed and tested and documentation reviewed.

Outpatient Services - Cardiac Rehab & Wellness Center at 1524 27th St.
Surveyor 27961
1. On 9/28/11 at 11:40 a.m., the Tamper could not be tested because the facility did not have one according to the Director, Construction Services.

SURVEYOR 29751
2. On 9/28/11 at 11:44 a.m., during water flow test, the outside alarm did not ring when the inside alarms were activated. This test was conducted twice and failed twice. Hospital staff confirmed the malfunction of the outside alarm during testing.


San Joaquin Community Hospital at 2615 Chester Avenue
SURVEYOR 27961
2. On 9/29/11 at 10:34 a.m., the paperwork from the monitoring company failed to indicate that the Water flow or Tamper had transmitted a signal to the monitoring company.

SURVEYOR 29751
3. On 9/28/11 at 2:30 p.m., on the 5th floor of Tower 2, in the house keeping closet Room 5-107 there was a sprinkler spray pattern obstructed by a 32 inch fluorescent light bulb.

Based on observation, the facility failed to maintain their automatic sprinkler system as evidenced by sprinklers that were not free of dust/debris. These findings could result in the fire sprinkler system not functioning as designed and increased risk of injury to patients and staff. This affected the Pre-Op area in Tower 1 of San Joaquin Community Hospital.

Findings:

During a tour of the facility with the Hospital Staff on September 27, 2011 through September 29, 2011, the sprinkler system was observed.

San Joaquin Community Hospital at 2615 Chester Avenue
SURVEYOR 27961
1. On 9/27/11 at 4:31 p.m., in Pre-Op area in Tower 1 there were 10 sprinklers covered in dust/debris.

Based on observation, the facility failed to maintain their fire extinguishers as evidenced the failure to mount the extinguishers according to NFPA 10, 1998 Edition. This could result in a delayed response to a fire and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected the 1st floor, Tower 2 of San Joaquin Community Hospital.

Findings:

During a tour of the facility with maintenance on September 28, 2011, the fire extinguishers were observed.

San Joaquin Community Hospital at 2615 Chester Avenue
SURVEYOR 29751
1. At 10:15 a.m., the 1st Floor MRI area in the doctor's lounge on Tower 2, there was a sign posted on the wall to the left of the entry indicating a fire extinguisher was mounted below. After observation of the area it was determined that there was no fire extinguisher under the sign or in the area of the sign. The absence of the fire extinguisher was confirmed by hospital staff touring the facility during survey.

NFPA 99 Health Care Facilities, 1999 Edition
4-3.1.1.1. Cylinder and Container Management. Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

Based on observation, the facility failed to ensure that the oxygen cylinders were properly secured as evidenced by unsecured oxygen tanks. This could cause harm to patients and staff in the event the cylinder fell on something or someone and/or the high pressure valve was damaged and caused the cylinder to move about in an uncontrolled manner. This affected the outside oxygen storage area at San Joaquin Community Hospital.

Findings:

During a tour of the facility with the Hospital Staff on September 27, 2011 through September 29, 2011, the facilities oxygen storage areas and tanks were observed.

San Joaquin Community Hospital at 2615 Chester Avenue
SURVEYOR 27961
1. On 9/28/11 at 10:50 a.m., there was a chain link fenced in area approximately 10 feet x 8 feet outside the facility that contained 54 H-Oxygen tanks which were secured with one chain across the front of them (picture attached).

NFPA 70 Section 400-8 1999 Ed. Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for a 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
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

Based on observation, the facility failed to maintain their electrical safety. This was evidenced by the use of multi outlet adapters, use of an extension cord, and broken ground ports. This could result in an increased risk of electrical fire and potential injury to residents and staff. This affected the 3rd floor and the 4th floor of San Joaquin Community Hospital.

Findings:

During a tour of the facility with the Hospital Staff on September 27, 2011 through September 29, 2011, the electrical system was observed.

San Joaquin Community Hospital at 2615 Chester Avenue
SURVEYOR 27961
1. On 9/27/11 at 3:15 p.m., in Equipment Room R3-4 on the 3rd floor in Tower 1 there was a microwave plugged into an extension cord and not directly into the electrical outlet in the wall.

SURVEYOR 29751
2. On 9/28/11 at 3:05 p.m., on the 4th Floor in Room 4214 of Tower 2, adjacent to Bed B, there was a broken faceplate cover on an electrical outlet exposing the interior of the wall.

3. On 9/28/11 at 3:09 p.m., on the 4th Floor in Room 4208 of Tower 2, adjacent to the restroom, there was an electrical outlet missing faceplate cover.

4. On 9/28/11 at 3:15 p.m., on the 4th floor in the Nursing Supervisors office of Tower 2, there was a refrigerator plugged into a surge protector.