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Based on document review and interview, the facility failed to maintain the emergency preparedness plan (EPP). This was evidenced by the failure to provide a patient population profile including persons at risk. This could result in the facility being unprepared during an emergency. This affected two of two patients.

Findings:

During a review of records and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/18/24, the EPP was reviewed.

At 3:01 p.m., a patient population profile was not available for review. Upon interview, the CAO stated that she did not know if they had a patient population profile because they were not a long-term care facility, and thus their patient load was always changing.

Based on document review and interview, the facility failed to maintain the emergency preparedness plan (EPP). This was evidenced by the failure to provide an 1135 waiver policy. This could result in the facility being unprepared during an emergency. This affected two of two patients.

Findings:

During a review of records and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/18/24, the EPP was reviewed.

At 3:55 p.m., an 1135 waiver policy was missing. Upon interview, the CAO stated that she was not familiar with what an 1135 waiver was. The CAO stated that if they needed to obtain any waivers, they would ask California Department of Public Health (CDPH).

Based on observation and interview, the facility failed to maintain the building's construction. This was evidenced by drop ceiling tiles that were removed and exposed the attic plenum space, and for unsealed penetrations. This could result in the passage of smoke or toxic gases from one part of the building to another. This affected two of two patients and four of four smoke compartments.

Findings:

During a tour of the facility and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/18/24, the building's construction was observed.

1. At 10:09 a.m., a 24 x 48-inch ceiling tile in the Activities Storage Closet on the B-Wing Nurses Station had been removed and was left unattended. Upon interview, the DOM stated that someone for the maintenance staff must have forgotten to put the tile back in place after working in the attic space.

2. At 10:18 a.m., a sprinkler in the corridor by CEOs Office was observed falling out of place by approximately one inch, resulting in an approximately two-inch penetration in the ceiling tile around the pipe. Upon interview, the DOM stated that he did not know how this happened and stated that someone could have taken the escutcheon down and did not put it up all the way.

3. At 10:43 a.m., a telecom port was observed in the Medical Records Room on the northwest wall behind a desk. This port was yanked out of the wall, leaving behind an approximately two by three-inch hole with exposed wires. Upon interview, the DOM stated that the equipment connected to this port was taken offline and no longer in use.

4. At 10:55 a.m., an approximately one-quarter inch penetration a ceiling tile on the southeast side of the Emergency Room waiting room. Upon interview, the DOM stated that the penetrations probably came from the wiring for the security cameras.

5. At 11:05 a.m. an approximately 24 x 48-inch drop ceiling tile was removed in the Dirty Utility Room in the ER Ward resulting in a ceiling penetration. Upon interview, the DOM stated that someone must have been working in the attic space and forgot to put the ceiling tile back.

6. At 11:38 a.m., an approximately one-quarter inch penetration was observed around the escutcheon ring of a sprinkler in the Laboratory Storage Room and around the escutcheon of one sprinkler in the corridor in front of the Laboratory Storage Room. Upon interview, the DOM stated that it looked like the escutcheon rings had been offset from their original place.

7. At 11:41 a.m., an approximately one-quarter inch penetration was observed around the escutcheon ring of a sprinkler on the south side of the smoke barrier doors in the corridor near the Laboratory Storage Room. Upon interview, the DOM stated that some of the maintenance staff had been in the attic to check the smoke dampers and they could have bent the sprinklers out of place.

8. At 12:10 p.m., four penetrations were observed on the south wall of the IT/Telecom Room. From the east wall to the west wall, the penetrations measured approximately one-half inch, one inch, one-third inch, and one and a half inches in diameter. Upon interview, the DOM stated that the IT company had installed new wiring, and they did not seal up the penetrations.

9. At 12:10 p.m., an approximately one-half inch penetration was observed on the northwest wall of the EVS Storage Room across from the IT Room. An ethernet cable was coming through the penetration. Upon interview, the DOM stated that he did not know what the ethernet cable was for.

10. At 12:59 p.m., an approximately one-quarter inch penetration was observed around the edge of a sprinkler escutcheon ring in the Scrubs Room located in the Operating Room Nurses' Station. The CAO observed this finding during the tour.

11. At 1:20 p.m., an approximately 24 x 48-inch drop ceiling tile was removed and left unattended in the Clean Utility Room of the Obstetrics and Labor ward resulting in a ceiling penetration. Upon interview, the DOM stated that one of his crew members was working in the attic space and forgot to put the tiles back.

12. At 1:29 p.m., two drop ceiling tiles were removed in the Laboratory Supply Room, which exposed the attic plenum space. The DOM and CAO observed this finding.

Based on observation and interview, the facility failed to maintain the doors with self-closing devices.. This was evidenced by an automatic closing door that was propped open with a floor wedge. This could result in a delay in preventing the spread of fire, smoke, or toxic gases. This affected staff and one of four smoke compartments.


Findings:

During a tour of the facility and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/18/24, the doors with self-closing devices were observed.

1. At 1:27 p.m., the door to the Nursery Room was propped open with a floor wedge. This door had an automatic closing device installed. Staff in the room were interviewed and stated that the door was wedged because it would get hot in the room.

Based on observation, document review, and interview, the facility failed to maintain the cooking equipment. This was evidenced by the failure to provide any documentation of service for the ANSUL suppression system, for missing one of two kitchen hood cleaning reports, and for a missing annual inspection for the fuel-fed commercial cooking equipment. This could result in a malfunction of the cooking facilities. This affected two of two patients and one of four smoke compartments.

NFPA 101: Life Safety Code, 2012 Edition
19.3.2.5 Cooking Facilities.
19.3.2.5.1
Cooking facilities shall be protected in accordance with 9.2.3, unless otherwise permitted by 19.3.2.5.2, 19.3.2.5.3, or 19.3.2.5.4.
9.2.3 Commercial Cooking Equipment.
Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations 2014 Edition.
10.2.6 Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer's instructions, and the following standards where applicable:
(4) NFPA 17A
11.2.1* Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person (s) acceptable to the authority having jurisdiction at least every six months.
11.4* Inspection for Grease Buildup.
The entire exhaust system shall be inspected for grease buildup by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction and in accordance with Table 11.4.
11.5 Inspection, Testing, and Maintenance of Listed Hoods Containing Mechanical, Water Spray, or Ultraviolet Devices. Listed hoods containing mechanical or fire-actuated dampers, internal washing components, or other mechanically operated devices shall be inspected and tested by properly trained, qualified, and certified persons every 6 months or at frequencies recommended by the manufacturer in accordance with their listings.
11.7 Cooking Equipment Maintenance.
11.7.1 Inspection and servicing of the cooking equipment shall be made at least annually by properly trained and qualified persons.

NFPA 17A, Standard for Wet Chemical Extinguishing Systems, 2009 Edition.
7.3.3* At least semiannually and after any system activation, maintenance shall be conducted in accordance with the manufacturer's design, installation, and maintenance manual.
7.3.3.6.1 The owner or owner's representative shall retain all maintenance reports for a period of 1 year after the next maintenance of that type required by the standard.
7.3.3.7* Each wet chemical system shall have a tag or label securely attached, indicating the month and year the maintenance is performed and identifying the person performing the service. Only the current tag or label shall remain in place.

Findings:

During a tour of the facility, review of documents, and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/18/24 and 6/19/24, the cooking facilities were observed.

1. On 6/18/24 at 11:54 a.m., the pull station tag for the ANSUL suppression system in the kitchen indicated that an annual service was done in March of 2023. Upon interview, the DOM stated that the vendor should have come out to service the suppression system when they did the fire extinguishers. On 6/19/24 at 9:28 a.m., the facility was unable to provide documentation of the most recent service for the kitchen suppression system. Upon interview, the DOM stated that he went to the kitchen staff to obtain all of their maintenance documentation, and the suppression system was not included.

2. On 6/19/24 at 9:26 a.m., one of two kitchen hood cleaning reports was not available for review. Upon interview, the DOM stated that they clean the vent filters once per month as preventative maintenance, but the vendor only came out once to clean the ducts and exhaust vents for the previous year.

3. On 6/19/24 at 9:49 a.m., there was no annual kitchen equipment inspection available for review. Upon interview, the DOM stated that he went to the kitchen staff to obtain all of their maintenance documentation and they did not have this report. The DOM stated that he did not know this was a requirement.

Based on observation and interview, the facility failed to maintain the alcohol-based hand rub (ABHR) dispensers. This was evidenced by ABHRs that were installed directly above and within one horizontal inch of an ignition source. This could result in fire hazards from flammable liquids encountering electricity. This affected two of two patients and two of four smoke compartments.


Findings:

During a tour of the facility and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/18/24, the ABHRs were observed.

1. At 10:35 a.m., an ABHR was observed on the south wall of the Admitting Office was less than one horizontal inch above an electrical outlet. The label on the liquid bladder stated that the solution contained 70% ethyl alcohol.

2. At 10:46 a.m., an ABHR was observed on the east wall of the Medical Records Room and was installed directly above four electrical outlets. Upon interview, the DOM stated that he did not know about this requirement and stated that it was the first time he had heard of this.

3. At 12:58 p.m., an ABHR on the south wall of the PACU Room in the Operating Room Nurses Station was installed directly above a light switch.

Based on document review and interview, the facility failed to maintain the fire alarm system (FAS). This was evidenced by the failure to replace Fire Alarm Control Panel (FACP) batteries, and for missing one of two load voltage tests for the FACP batteries. This could result in a malfunction of the FAS. This affected two of two patients and four of four smoke compartments.

NFPA 101, life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.
9.6 Fire Detection, Alarm, and Communications Systems.
9.6.1 * General.
9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.
9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition
Table 14.3.1 column 2 heading was revised by a tentative interim amendment (TIA).
Table 14.3.1 Visual Inspection Frequencies
3. Batteries
(d) Sealed lead-acid: Initial/Reacceptance; Semiannually
5. Fire alarm control unit trouble signals: Weekly; Semiannually
8. Remote annunciators: Initial/Reacceptance; Semiannually
9. Initiating devices
(f) Heat Detectors: Initial/Reacceptance; Semiannually
(h) Smoke detectors: Initial/Reacceptance; Semiannually
(i) Supervisory signal devices: Initial/Reacceptance; Semiannually
14.4.2* Test Methods.
14.4.2.2* Systems and associated equipment shall be tested according to Table 14.4.2.2.
5. Batteries-general tests: Prior to conducting any battery testing, the person conducting the test shall ensure that all system software stored in volatile memory is protected from loss.
(a) Visual inspection: Batteries shall be inspected for corrosion or leakage. Tightness of connections shall be checked and ensured. If necessary, battery terminals or connections shall be cleaned and coated. Electrolyte level in lead-acid batteries shall be visually inspected.
(e) Load voltage test: With the battery charger disconnected, the terminal voltage shall be measured while supplying the maximum load required by its application. The voltage level shall not fall below the levels specified for the specific type of battery. If the voltage falls below the level specified, corrective action shall be taken and the batteries shall be retested.
6. Battery tests (specific types)
(d) Sealed lead-acid type
(2) Load voltage test: Under load, the battery shall perform in accordance with the battery
manufacturer ' s specifications.
14.4.5* Testing Frequency. Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction.
Table 14.4.5 Testing Frequencies
6. Batteries-fire alarm systems
(d) Sealed lead-acid type
6. Batteries-fire alarm systems
(d) Sealed lead-acid type
Annually
(3) Load voltage test - Initial/Reacceptance; Semiannually

Findings:

During a review of documents and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/19/24, records were requested and reviewed.

1. At 9:55 a.m., the Annual FAS Report dated 5/31/24 stated that the 1st floor electrical room required both Power Supply Panels to be replaced, the 1st floor FACP top power supply panel needed to be replaced, and the main FACP batteries needed to be replaced. This report also indicated that the sealed lead acid (SLA) batteries on the FACP were not tested for charging, discharging, and for load voltage. Upon interview, the DOM stated that the batteries had not been replaced yet because he had been too busy. He also stated that the batteries were not tested because of the vendors recommendations that they be replaced.

2. At 10:00 a.m., one of two semi-annual visual inspections for the duct detectors was missing. Upon interview, the DOM stated that they did monthly visual inspections to all the FAS components except for the duct detectors. He stated that he believed that the vendor came out on a semiannual basis to inspect the duct detectors, but he was not able to find the report.

Based on document review and interview, the facility failed to maintain the smoke detectors. This was evidenced by the failure to perform sensitivity testing on the smoke detectors. This could result in a malfunction of the smoke detectors. This affected two of two patients and four of four smoke compartments.

NFPA 101, life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.
9.6 Fire Detection, Alarm, and Communications Systems.
9.6.1 * General.
9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.
9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition
14.4.4* Testing Frequency.
14.4.4.3 *
In other than one- and two-family dwellings, sensitivity of smoke detectors shall be tested in accordance with 14.4.4.3.1 through 14.4.4.3.7.
14.4.4.3.1
Sensitivity shall be checked within 1 year after installation.

14.4.4.3.2
Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.4.3.3.

14.4.4.3.3
After the second required calibration test, if sensitivity tests indicate that the device has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years.

Findings:

During a review of records and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/19/24, the smoke detectors were observed.

At 10:02 a.m., a smoke detector sensitivity report was missing. Upon interview, the DOM stated that sensitivity testing was not done on the annual Fire Aalarm System report, and he did not know it was required.

Based on observation and interview, the facility failed to maintain the sprinkler system. This was evidenced by sprinkler pendants that did not have a minimum of 18 inches of clearance from the bottom of the deflector, and for a sprinkler that was obstructed by a light fixture. This could result in a malfunction of the sprinkler system. This affected two of two patients and two of four smoke compartments.

NFPA 101: Life Safety Code, 2012 Edition
19.3.5.4* The sprinkler system required by 19.3.5.1 or 19.3.5.3 shall be installed in accordance with 9.7.1.1
9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following:
(1) NFPA 13, Standard for the Installation of Sprinkler Systems

NFPA 13: Standard for the Installation of Sprinkler Systems, 2013 Edition
8.5.6 * Clearance to Storage.
8.5.6.1 * Unless the requirements of 8.5.6.2, 8.5.6.3, 8.5.6.4, or 8.5.6.5 are met, the clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.
8.10.6 Obstructions to Sprinkler Discharge (Residential Upright and Pendent Spray Sprinklers).
8.10.6.1 Performance Objective.
8.10.6.1.1 Sprinklers shall be located so as to minimize obstructions to discharge as defined in 8.10.6.2 and 8.10.6.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard.
8.10.6.1.2 Sprinklers shall be arranged to comply with one of the following arrangements:
(1) Sprinklers shall be in accordance with 8.5.5.2, Table 8.10.6.1.2, and Figure 8.10.6.1.2(a).
(2) Sprinklers shall be permitted to be spaced on opposite sides of obstructions not exceeding 4 ft (1.2 m) in width, provided the distance from the centerline of the obstruction to the sprinklers does not exceed one-half the allowable distance permitted between sprinklers.
(3) Obstructions located against the wall and that are not over 30 in. (762 mm) in width shall be permitted to be protected in accordance with Figure 8.10.6.1.2(b).
(4) Obstructions that are located against the wall and that are not over 24 in. (610 mm) in width shall be permitted to be protected in accordance with Figure 8.10.6.1.2(c). The maximum distance between the sprinkler and the wall shall be measured from the sprinkler to the wall behind the obstruction and not to the face of the obstruction.

Findings:

During a tour of the facility and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/18/24, the sprinkler system was observed.

1. At 9:56 a.m., two sprinkler pendants in the Room 204 Storage area had approximately 15-inches of clearance between the bottom of the deflector and the top of some storage boxes. These sprinklers were located on the south side of the room. Upon interview, the DOM stated that the boxes were all PPE that the county sent them.

2. At 11:21 a.m., the X-Ray Film Room had a light fixture that was obstructing a sprinkler pendant. The bottom of the light fixture measured approximately seven and a half inches beneath the sprinkler deflector, and less than one horizontal inch away from sprinkler. Upon interview, the DOM stated that he could see how the light fixture would obstruct the sprinkler spray pattern.

Based on observation and interview, the facility failed to maintain the sprinkler system. This was evidenced by a supervisory device that did not activate. This affected two of two patients and two of four smoke compartments.

NFPA 101, life Safety Code, 2012 Edition
19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.
9.7.2 Supervision.
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 and Signaling Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. 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.

Findings:

During a tour of the facility and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/18/24, the sprinkler system was observed.

At 2:05 p.m., the post indicator valve (PIV) was fully closed, and the exterior alarm bell nearby did not activate. The fire alarm control panel (FACP) annunciator in the IT/Telecom room had a supervisory LED flashing, but the LCD display was too dim to read what error it was giving. Upon interview, the DOM stated that the PIV had a tamper switch that was connected to an exterior alarm bell.

Based on observation and interview, the facility failed to maintain the sprinkler system. This was evidenced by sprinkler pendants that were corroded, or calcified, sprinkler heads that were intermingled, and for missing maintenance documentation. This could result in a malfunction of the sprinkler system. This affected two of two patients and four of four smoke compartments.


NFPA 101, Life Safety Code, 2012 Edition
19.3.5.3 Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7
19.3.5.4* The sprinkler system required by 19.3.5.1 or 19.3.5.3 shall be installed in accordance with 9.7.1.1
9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following:
(1) NFPA 13, Standard for the Installation of Sprinkler Systems
9.7.5 Maintenance and Testing.
All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 13: Standard for the Installation of Sprinkler Systems, 2013 Edition
6.2.7 Escutcheons and Cover Plates.
6.2.7.1
Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler.
8.3.3.2 Where quick-response sprinklers are installed, all sprinklers within a compartment shall be quick-response unless otherwise permitted in 8.3.3.3.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition.
5.2* Inspection.
5.2.1 Sprinklers.
5.2.1.1* Sprinklers shall be inspected from the floor level annually.
5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, pain, and physical damage; and shall be installed in the correct orientation (e.g., up-right, pendent, or sidewall).
5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5) *Loading
(6) Painting unless painted by the sprinkler manufacturer.

5.1.1.2
Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.
13.1.1.2
Table 13.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.
5.3.1.1.1 Where sprinklers have been in service for 50 years, they shall be replaced or representative samples from one or more sample areas shall be tested.
5.3.3.2 *
Vane-type and pressure switch-type waterflow alarm devices shall be tested semiannually.


Findings:

During a tour of the facility and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/18/24, the sprinkler system was observed.

1. At 10:12 a.m., a corroded sprinkler was observed in the bathroom of the physical therapy room on the B-Wing. The sprinkler had calcified water deposits on the red glass bulb and around the base of the pendant. Upon interview, the DOM stated that he did not know if the sprinkler was leaking and stated that the vendor was recently at the facility and did not comment on this sprinkler.

2. At 11:35 a.m., a green, corroded sprinkler was observed in the Bathroom of the Doctor's Sleeping Room. The DOM and CAO observed this finding.

3. At 11:50 a.m., intermingled sprinkler heads were observed in the Kitchen storage area and consisted of one quick-response (QR) pendant and one standard sidewall mounted fusible link type sprinkler. Upon interview, the DOM stated that the sprinkler vendor recently came to the facility to collect expired sprinklers and send them to a lab for testing and it was possible that they installed the QR sprinklers in place of the ones they took.

4. At 11:52 a.m., a sidewall mounted fusible link sprinkler was observed in the bathroom in the kitchen and was painted over. Upon interview, the DOM stated that he did not know who painted in this area and did not know that the sprinkler was painted over.

5. At 11:59 a.m., a sprinkler in the laundry room near the entrance was missing an escutcheon. The DOM and CAO confirmed this finding.

6. At 1:45 p.m., two intermingled sprinklers were observed in Room 109 and consisted of one QR head and one sidewall mounted fusible link sprinkler. The DOM observed this finding and stated that the sprinkler vendor came to the facility to collect expired sprinklers to send to a lab for testing and they probably installed the QR sprinkler heads in place of the ones that they took.

7. At 1:51 p.m., intermingled heads were observed in the ICU ward. The ICU contained standard sprinkler heads throughout the suite, as well as one QR sprinkler in the nurse's station area and one QR sprinkler in the room that used to be ICU Room 2. The DOM Stated that they did not have an ICU anymore and that the suite was mostly used for storage. He stated that he did not know about the intermingled sprinkler heads because people seldom went into this suite.

8. At 10:11 a.m., the annual sprinkler report was missing. Upon interview, the DOM stated that he thought the five-year sprinkler report and the annual fire alarm system report were enough to meet the requirements. The most recent five-year sprinkler service was performed on 4/12/2019, and the annual fire alarm system report did not include testing for all the sprinkler system components.

9. At 10:12 a.m., the facility was missing two of two semi-annual waterflow tests for the vane and pressure switches on the sprinkler system. Upon interview, the DOM stated that they were not testing the waterflow devices in house.

Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by doors that were obstructed or propped open with wedges. This could result in a delay in preventing fire or smoke from entering the corridor. This affected two of two patients and four of four smoke compartments.

Findings:

During a tour of the facility and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/18/24, the corridor doors were observed.

1. At 9:54 a.m., a helipad patient gurney was left unattended in the door swinging path of Room 204 in the B-Wing obstructing the door from closing. Upon interview, the DOM stated that the room was used for storage and the gurney should have been pushed all the way in the room.

2. At 10:51 a.m., the door to the Respiratory Therapy Manager's Office was wedged by a trash bin, preventing the door from closing. Upon interview, the DOM stated that sometimes the housekeeping staff would leave the trash bins in doorways like this.

3. At 11:03 a.m., in Room 3 in the Emergency Room Suite an automatic closing device was installed on the door, and the arm for the door closer was disconnected. Upon interview, the DOM stated that the arms for the automatic closers were disconnected on purpose because one of the old administrators asked that they be removed. The DOM stated that old administrator was no longer with the facility and that the automatic closing devices had been disconnected for a long time.

4. At 11:10 a.m., Room 4 in the Emergency Room Suite had an automatic closing device installed on the door, and the arm for the door closer was disconnected.

5. At 11:19 a.m., the door to the Personnel Lounge in the X-ray wing was wedged open with a floor wedge. This door was located on a corridor and had an automatic closing device installed. Upon interview, the DOM stated that sometimes the staff in this area would prop open the doors to promote air flow.

6. At 11:23 a.m., the east exit door of the X-ray room was wedged open with a floor wedge. This door was located on a corridor and had an automatic closing device installed. Upon interview, the DOM stated that sometimes the staff would prop open the doors with wedges because they had wheelchair bound patients and they did not want to have to keep opening the doors.

7. At 11:25 a.m., the east door of the Radiology Room was wedged open with a floor wedge. The door was located on a corridor and had an automatic closing device installed. Upon interview, the DOM stated that sometimes the staff in the area would prop open the doors with floor wedges so that they could easily move wheelchair bound to patients into the radiology room.

8. At 12:00 p.m., a sterilization cabinet was pressed against the corridor door with a self-closing device to the south Laundry Room Area obstructing the door from closing. Deep scrape marks were observed along the side of the sterilization cabinet. Upon interview, the CAO stated that the sterilization cabinet was supposed to be on the other side of the room, and she did not know why it was placed so close to the corridor door.

Based on observation and interview, the facility failed to maintain the heating, ventilation, and air conditioning (HVAC) system. This was evidenced by blocked off exhaust vents. This could result in a malfunction of the HVAC system. This affected two of two patients and two of four smoke compartments.

19.5 Building Services.
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.
19.5.2 Heating, Ventilating, and Air-Conditioning.
19.5.2.1 Heating, ventilating, and air-conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer ' s specifications, unless otherwise modified by 19.5.2.2.
9.2.1 Air-Conditioning, Heating, Ventilating Ductwork, and Related Equipment.
Air-conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 90A: Standard for the Installation of Air-Conditioning and Ventilating Systems, 2012 Edition
4.3.8.3.2
9.2.2 Ventilating or Heat-Producing Equipment.
Ventilating or heat-producing equipment shall be in accordance with NFPA 91, Standard for Exhaust Systems for Air Conveying of Vapors, Gases, Mists, and Noncombustible Particulate Solids; NFPA 211, Standard for Chimneys, Fireplaces, Vents, and Solid Fuel-Burning Appliances; NFPA 31, Standard for the Installation of Oil-Burning Equipment; NFPA 54, National Fuel Gas Code; or NFPA 70, National Electrical Code, as applicable, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 91: Standard for Exhaust Systems for Air Conveying of Vapors, Gases, Mists, and Particulate Solids, 2010 Edition
10.2 General.
Exhaust systems shall be tested, inspected, and maintained to ensure safe operating conditions.
10.2.1 The responsibility for maintenance shall be assigned to trained personnel who are capable of recognizing potential hazards.
10.2.2 Maintenance shall include the determination that special protection for duct systems is fully operable and that plant automatic sprinkler protection is in service.

Findings:

During a tour of the facility and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/18/24, the HVAC system was observed.

1. At 12:10 p.m., an HVAC exhaust vent was observed in the EVS Storage Room and was sealed off with cardboard and duct tape. Upon interview, the DOM stated that he did not know what was going with the sealed off exhaust vent, and he did not know who would have taped it off.

2. At 1:36 p.m., an exhaust vent in the bathroom of Room 101 was stuffed with tissue paper. Upon interview, the DOM stated that he did not know why the vent was sealed off.

Based on observation and interview, the facility failed to maintain the smoking regulations. This was evidenced by smoking materials that were not disposed of in approved ashtrays. This could result in fire hazards from smoking materials encountering combustible materials. This affected the smoking area..

Findings:

During a tour of the facility and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/18/24, the smoking areas were observed.

At 10:57 a.m., the smoking area on the west patio of the Emergency Room waiting area had about 10 cigarette butts in the rocks, grass, and in the surrounding area. Upon interview, the DOM stated that most of the smoking materials came from visitors.

Based on observation, document review, and interview, the facility failed to maintain the gas and vacuum systems. This was evidenced by a missing inspection/testing documentation for the piped in medical gas. This could result in a malfunction of the piped in medical gas system. This affected two of two patients and four of four smoke compartments.

Findings:

During a tour of the facility, review of documents, and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/18/24 and 6/19/24, the piped in medical gas equipment was observed.

1. On 6/18/24 at 1:14 p.m., the Zone Valve #9 oxygen shutoff valve located in the Labor Room and Obstetrics Clinic had sticker on the zone valve window dated 4/2/20. The ball valve handle was also broken off. Upon interview, the DOM stated that the ball valve handle was removed because they do not use this area of the hospital anymore, and that they were not licensed for obstetrics or labor and delivery. He also stated that he thought the vendor had come out to the facility to service the medical gas more recently than 2020.

2. On 6/18/24 at 1:42 a.m., the main oxygen shutoff valve for the sub-acute and ICU zone valve had sticker on the window that was dated 4/2/20. Upon interview, the DOM stated that they no longer utilized the sub-acute and ICU wards, however, he thought that the medical gas had been serviced since 2020.

3. On 6/18/24 at 12:56 p.m., Zone Valve #5 oxygen shutoff in Operating Room Nurses Station had sticker on the window that stated the last inspection was done was done on 4/2/20. Upon interview, the DOM and CAO stated that they did not know inspections were required on zone valves. The DOM stated that since he took over, the system had not been inspected.

4. On 6/19/24 at 9:41 a.m., the inspection/testing documentation for the piped in medical gas was missing. Upon interview, the DOM stated that he was unable to find any maintenance documentation for the piped in medical gas, and that they would perform walkthroughs and visually checked for leaks on the oxygen lines on a quarterly basis, but they did not have a report from a vendor.

Based on document review and interview, the facility failed to maintain the essential electrical equipment (EES). This was evidenced by missing documentation for a 90-minute load bank test for the backup diesel generator, 4-hour load bank test for the diesel generator, and a missing annual fuel quality test. This could result in a malfunction of the EES. This affected two of two patients and four of four smoke compartments.

NFPA 101, Life Safety Code, 2012 Edition.
19.5 Building Services.
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.
9.1.3.1 Emergency generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.
NFPA99, Health Care Facilities Code, 2012 Edition
6.3.2.2.10 Essential Electrical Systems (EES)
6.3.2.2.10.2 General care rooms (Category 2 Room) Shall be served by a Type I or Type II EES.
6.4.1.1.6 General. Generator sets installed as an alternate source of power for essential electrical systems shall be designed to meet the requirements of such a device.
6.4.4.1.1.3 Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 8.
6.4.4.2 Record Keeping. A written record of inspection, performance, exercise period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.
6.5.1 Sources (Type 2 EES). This requirement for sources for Type 2 essential electrical systems shall conform to those listed in 6.4.1.

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

8.4.9.7 Where the test required in 8.4.9 is combined with the annual load bank test, the first 3 hours shall be at not less than the minimum loading required by 8.4.9.5 and the remaining hour shall be at not less than 75 percent of the nameplate kW rating of the EPS.
8.4.9* Level 1 EPSS shall be tested at least once within every 36 months.
8.4.9.1 Level 1 EPSS shall be tested continuously for the duration of its assigned class (see Section 4.2).
8.4.9.2 Where the assigned class is greater than 4 hours, it shall be permitted to terminate the test after 4 continuous hours.
8.4.9.5.3 For spark-ignited EPSs, loading shall be the available EPSS load.

Findings:

During a review of documents and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/19/24, the EES was observed, and maintenance documents were requested.

1. At 9:37 a.m., a 4-hour load bank test for the emergency diesel generator was missing. Upon interview, the DOM stated that he did not know a 4-hour load bank test was required. The DOM stated that he became the maintenance director about three years ago and was still learning the ropes. He stated that they had the capacity to perform a load bank test on site, he just did not know that one was required.

2. At 9:10 a.m., an annual fuel quality test was missing. Upon interview, the DOM stated that he did not know that was a requirement. Upon interview, the DOM stated that he inherited the position of maintenance lead about three years ago, right before the COVID-19 pandemic. He stated that he was still getting familiar with all of the requirements.

This was a previous finding captured on the previous life safety code recertification survey from on 3/14/2018.

3. At 9:35 a.m. the 90-minute load bank test for the emergency diesel generator was missing. Upon interview, the DOM stated that he did not know this was required. He stated that he was told by the county that they could only run the generator for a certain number of hours in a year.

Based on observation and interview, the facility failed to maintain the electrical equipment. This was evidenced by two power strips that were connected to each other (Daisy-Chained). This could result in electrical shocks or fire hazards from connected electrical equipment. This affected two of two patients and one of four smoke compartments.

NFPA 101, Life Safety Code, 2012 Edition.
19.5 Building Services.
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70, National Electrical Code, 2011 Edition
400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the
following:
(1) As a substitute for the fixed wiring of a structure.
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.
(3) Where run through doorways, windows, or similar openings.
(4) Where attached to building surfaces
Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B)
(5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings.
(6) Where installed in raceways, except as otherwise permitted in this Code.
(7) Where subject to physical damage
590.3 Time Constraints.
(A) During the Period of Construction. Temporary electric power and lighting installations shall be permitted during the period of construction, remodeling, maintenance, repair, or demolition of buildings, structures, equipment, or similar activities.
(B) 90 Days. Temporary electric power and lighting installations shall be permitted for a period not to exceed 90 days for holiday decorative lighting and similar purposes.
(C) Emergencies and Tests. Temporary electric power and lighting installations shall be permitted during emergencies and for tests, experiments, and developmental work.
(D) Removal. Temporary wiring shall be removed immediately upon completion of construction or purpose for which the wiring was installed.

Findings:

During a tour of the facility and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/18/24, the electrical equipment was observed.

At 10:27 a.m., two power strips were under a desk in the Business Offices in the B-wing that were daisy-chained together. Upon interview, the DOM stated that he did not know the power strips were connected this way.

Based on document review and interview, the facility failed to maintain the gas equipment. This was evidenced by the failure to provide continuing education for staff on oxygen tank handling. This could result in a delay in procuring oxygen tanks or damage from mishandling oxygen cylinders. This affected two of two patients and four of four smoke compartments.

Findings:

During a review of records and interview with the Chief Ancillary Officer (CAO) and Director of Maintenance (DOM) on 6/18/24, the training policy for oxygen tank handling was requested.

At 10:06 a.m., the facility was not able to provide a training policy or curriculum for how to handle oxygen tanks. Upon interview, the CAO stated that the facility had a generalized policy on handling and responding to an oxygen related issue, but this policy was not part of their continuing education curriculum.