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Based on record review and interview, the facility failed to maintain the emergency battery backup lighting units. This was evidenced by the failure to test the emergency lighting units. This affected the Emergency Room, Operating Room and Generator enclosure and could result in a failure to provide backup lighting in the event of an emergency.

NFPA 101: Life Safety Code, 2012 Edition
19.2.9 Emergency Lighting.
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.
7.9 Emergency Lighting.
7.9.2 Performance of System.
7.9.2.1 * Emergency illumination shall be provided for a minimum of 1 1/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10.8 lux) and, at any point, not less than 0.1 ft-candle (1.1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6.5 lux) and, at any point, not less than 0.06 ft-candle (0.65 lux) at the end of 11/ 2 hours. A maximum-to-minimum illumination uniformity ratio of 40 to 1 shall not be exceeded.
7.9.2.3 * The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any interruption of normal lighting due to any of the following:
(1) Failure of a public utility or other outside electrical power supply
(2) Opening of a circuit breaker or fuse
(3) Manual act(s), including accidental opening of a switch controlling normal lighting facilities
7.9.3 Periodic Testing of Emergency Lighting Equipment.
7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.
7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).
(2)* The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 11/ 2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During a tour of the facility, record review and interview with Engineering Staff on 7/15/25, the emergency lighting was observed and records reviewed.

1. At 2:24 p.m., the Emergency Room and the Operating Room were observed with battery backup emergency lighting units mounted on the wall. The facility failed to provide documentation that monthly 30 second functional tests on the emergency lighting units during the last 12 months. Upon interview, ES3 stated that he was not aware that those units required testing.

2. At 2:24 p.m., the Emergency Room and the Operating Room were observed with battery backup emergency lighting units mounted on the wall. The facility failed to provide documentation that the annual 90-minute functional test had been conducted on the emergency lighting units during the last 12 months. Upon interview, ES3 stated that he was not aware that those units required testing.

3. At 2:26 p.m., the generator enclosure was observed with a battery backup emergency lighting unit mounted on the wall above the generator. The facility failed to provide documentation that the annual 90-minute functional test was conducted on the emergency lighting unit during the last 12 months. Upon interview, ES3 stated that he was not aware that those units required testing.

Based on observation and interview, the facility failed to maintain the hazardous area enclosures. This was evidenced by corridor doors that failed to latch. This affected five of five patients and one of three smoke compartments and could result in the spread of smoke and fire.

Findings:

During a tour of the facility and interview with Maintenance Staff on 7/15/25, the hazardous enclosure areas were observed.

At 12:23 p.m., the double corridor doors the central supply storage room was observed. The latch bolt had been removed from the doors latching hardware, preventing the doors from positively latching. Upon interview, ES2 acknowledged that the doors were missing the latch bolt and failed to latch when tested.

Based on record review and interview, the facility failed to maintain the anesthetizing locations. This was evidenced by the failure to provide records of relative humidity (RH) and temperature documentation. This affected the operating room and could result in the increased risk of a hazardous condition and fire.

Findings:

During record review and interview with Maintenance Staff on 7/15/25, the temperature and RH logs were requested.

At 11:10 a.m., the facility failed to provide temperature and RH logs for the single operating room (OR) in the facility. Upon interview, ES1 stated that there was a sensor on the wall in the OR that alerts the engineering department when the temperature was out of range. ES1 further stated that nursing staff would have access to the temperature and RH logs. Nursing staff were contacted over the phone and stated that temperature and RH were logged in an online program. ES1 stated that he did not have access to that program and was unable to provide the logs.

Based on record review, and interview, the facility failed to maintain the fire alarm system (FAS). This was evidenced by the failure to conduct semiannual inspections, replace failed fire alarm control panel (FACP) batteries and test the notification devices. This affected five of five patients and three of three smoke compartments and could result in the delay of notification to emergency forces in the event of an emergency.

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.
9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

NFPA 72: National Fire Alarm and Signaling Code, 2010 Edition
Chapter 14 Inspection, Testing, and Maintenance
14.1 Application.
14.1.1 The inspection, testing, and maintenance of systems, their initiating devices, and notification appliances shall comply with the requirements of this chapter.
14.3 Inspection.
14.3.1 * Unless otherwise permitted by 14.3.2 visual inspections shall be performed in accordance with the schedules in Table 14.3.1 or more often if required by the authority having jurisdiction.
14.3.2 Devices or equipment that is inaccessible for safety considerations (e.g., continuous process operations, energized electrical equipment, radiation, and excessive height) shall be permitted to be inspected during scheduled shutdowns if approved by the authority having jurisdiction.
14.3.4 The visual inspection shall be made to ensure that there are no changes that affect equipment performance.
Table 14.3.1 Visual Inspection Frequencies-semiannually
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.
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- Annually
1. Control equipment - building systems connected to supervising station
(a) Functions
(b) Fuses
(c) Interfaced equipment
(d) Lamps and LEDs
(e) Primary (main) power supply
(f) Transponders
Batteries - fire alarm systems
6. (d) Sealed lead-acid type
(1) Charger test: (Annually.)
(2) Discharge test (30 minutes): Annually
(3) Load voltage test: Semiannually
8. Fiber-optic cable power
9. Control unit trouble signals
12. In-building fire emergency voice/alarm communications equipment
14. Remote Annunciators
15. Initiating Devices*
(a) Duct detectors
(b) Electromechanical releasing device
(c) Fire extinguishing system(s) or suppression system(s) switches
(d) Fire-gas and other detectors
(e) Heat detectors (The requirements of 14.4.5.5 shall apply.)
(f) Manual fire alarm boxes
(h) System smoke detectors - functional test
(j) Single- and multiple-station smoke alarms (The requirements for monthly testing in accordance with 14.4.6 shall also apply.)
(k) Single- and multiple-station heat alarms
20. Alarm notification appliances
(a) Audible devices
(b) Audible textual notification appliances
(c) Visible devices
14.6.2 Maintenance, Inspection, and Testing Records.
14.6.2.1 Records shall be retained until the next test and for 1 year thereafter.
14.6.2.4 * A record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 14.6.2.4:
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested
(8) Functional test of detectors
(9)* Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Functional test of mass notification system control units
(13) Functional test of signal transmission to mass notification systems
(14) Functional test of ability of mass notification system to silence fire alarm notification appliances
(15) Tests of intelligibility of mass notification system speakers
(16) Other tests as required by the equipment manufacturer's published instructions
(17) Other tests as required by the authority having jurisdiction
(18) Signatures of tester and approved authority representative
(19) Disposition of problems identified during test (e.g., system owner notified, problem corrected/successfully retested, device abandoned in place)

Findings:

During a tour of the facility, record review and interview with Maintenance Staff on 7/15/25, the FAS was observed and records reviewed.

1. At 2:41 p.m., the annual FAS testing and inspection documentation dated 5/7/25 was reviewed. The documentation indicated two sealed lead acid batteries in the FACP had failed the load voltage test. No repair record was provided. Upon interview, ES2 stated that the vendor was going to replace both batteries.

2. At 2:45 p.m., the annual FAS testing and inspection documentation dated 5/7/25 was reviewed. The documentation indicated the notification appliances were not tested during the annual testing and inspection. Upon interview, ES2 acknowledged that the notification appliances were not tested.

3. At 2:52 p.m., the facility failed to provide a semiannual fire alarm inspection documentation. The annual maintenance and inspection were conducted on 5/7/25 and the inspection conducted previous was on 8/26/24. Upon interview, ES2 stated that their vendor was out at the end of last year and he would get the records from them.

The facility was given until 10:00 a.m. on 7/16/25 to provide the FAS records to the California Department of Public Health (CDPH).

At 10:00 a.m. on 7/16/25, CDPH did not receive the FAS records from the facility.

Based on record review and interview, the facility failed to maintain the interim fire measures. This was evidenced by incomplete fire watch policy and procedure. This affected five of five patients and three of three smoke compartments and could result in the facility not notifying the authority having jurisdiction (AHJ) during a fire watch event.

Findings:

During record review and interview with Maintenance Staff on 7/15/25, the interim fire measures and policies were reviewed.

At 1:44 p.m., the facility's fire watch policy was reviewed. The policy failed to include directions that the facility would notify the California Department of Public Health (CDPH) when a fire watch was implemented during a failed fire alarm system. Upon interview, the ES1 acknowledged the policy was missing instructions to notify CDPH when a fire watch was implemented.

Based on observation and interview, the facility failed to maintain the fire sprinkler system. This was evidenced by missing an identification sign. This affected five of five patients and three of three smoke compartments and could result in a delay to identifying the main control valve.

NFPA 101: Life Safety Code, 2012 Edition
19.3.5 Extinguishment Requirements.
19.3.5.1
Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.
9.7 Automatic Sprinklers and Other Extinguishing Equipment.
9.7.1 Automatic Sprinklers.
9.7.1.1 * 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, 2010 Edition
6.7.4 * Identification of Valves.
6.7.4.1 All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs.
6.7.4.2 The identification sign shall be secured with corrosion-resistant wire, chain, or other approved means.

Findings:

During a tour of the facility and interview with Maintenance Staff on 7/15/25, the fire sprinkler system was observed.

At 11:37 a.m., the main control valve on the fire sprinkler riser located in the boiler/mechanical room was observed. The main control valve was missing an identification sign. Upon interview, ES2 acknowledged that the sign was missing.

Based on observation and interview, the facility failed to maintain the fire sprinklers. This was evidenced by an obstructed fire sprinkler head. This affected five of five patients and one of three smoke compartments and could result in the malfunction of the sprinklers in the event of a fire.

NFPA 101: Life Safety Code, 2012 Edition
19.3.5 Extinguishment Requirements.
19.3.5.1
Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.
9.7 Automatic Sprinklers and Other Extinguishing Equipment.
9.7.1 Automatic Sprinklers.
9.7.1.1 * 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, 2010 Edition
8.10.6.3 * Obstructions That Prevent Sprinkler Discharge from Reaching the Hazard.
8.10.6.3.1 Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 8.10.6.3.

Findings:

During a tour of the facility and interview with Maintenance Staff on 7/15/25, the automatic sprinkler system was observed.

At 12:41 p.m., the storage room near the Nurse Station was observed. Two cardboard boxes on the top shelf of the closet were approximately seven inches below the single sprinkler head in the closet. Upon interview, the ES2 acknowledged that the sprinkler was obstructed.

Based on record review and interview, the facility failed to maintain the interim fire measures. This was evidenced by incomplete fire watch policy and procedure. This affected five of five patients and three of three smoke compartments and could result in the facility not notifying the Authority Having Jurisdiction (AHJ) during a fire watch.

Findings:

During record review and interview with Maintenance Staff on 7/15/25, the interim fire measures policies were reviewed.

At 1:45 p.m., the facility's fire watch policy was reviewed. The policy failed to include directions that the facility would notify the California Department of Public Health (CDPH) when a fire watch was implemented during a failed automatic fire sprinkler system. Upon interview, the ES1 acknowledged the policy was missing instructions to notify CDPH when a fire watch was implemented.

Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by corridor doors that failed to latch and were obstructed from closing. This affected five of five patients and three of three smoke compartments and could result in the spread of fire or smoke in the event of a fire.

Findings:

During a tour of the facility and interview with Maintenance Staff on 7/15/25, the corridor doors were observed.

1. At 11:54 a.m., the corridor door to the Biohazard closet failed to latch when tested. The door was equipped with a self-closing device and was tested three times. Upon interview, ES2 acknowledged that the door failed to latch.

2. At 11:55 a.m., the corridor door to the Physical Therapy Room was obstructed from closing. A rubber wedge was under the door leaf, holding the door in the fully open position. Upon interview, ES2 acknowledged that the door was obstructed from closing.

3. At 11:56 a.m., the corridor door to the Physical Therapy Room failed to latch when tested. The door was equipped with a self-closing device and was tested three times. Upon interview, ES2 acknowledged that the door failed to latch.

4. At 12:14 p.m., the corridor door to the Employee Break Room failed to latch when tested. The door was equipped with a self-closing device and was tested three times. Upon interview, ES2 acknowledged that the door failed to latch.

5. At 12:37 p.m., the corridor door to the emergency room was obstructed from closing. Two plastic bags and a backpack were stored on the floor directly in front of the door, preventing it from being closed. Upon interview, ES2 acknowledged that the door was obstructed from closing.

Based on observation and interview, the facility failed to maintain the smoke barrier walls. This was evidenced by penetrations in the smoke barrier wall in the attic. This affected five of five patients and two of three smoke compartments and could result in the spread of smoke to adjacent smoke compartments during a fire.

NAPA 101, Life Safety Code, 2012 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2-hour fire resistance rating, unless otherwise permitted by one of the following:
(1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:
(a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(ac).
(B) Not less than two separate smoke compartments shall be provided on each floor.
(2) Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier.
8.5.6.2 Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.
8.5.6.3 Where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8.3.5 to limit the spread of fire for a time period equal to the fire resistance rating of the assembly and 8.5.6 to restrict the transfer of smoke, unless the requirements of 8.5.6.4 are met.

Findings:

During a tour of the facility and interview with Maintenance Staff on 7/15/25, the smoke barrier walls were observed.

1. At 12:49 p.m., the smoke barrier wall above the 90-minute fire barrier doors between the Lobby and the Acute side of the Hospital were observed. Approximately two-inch diameter metal conduit was observed running through the smoke barrier wall. Two wires were run through the conduit and the conduit was not sealed at the end to resist the passage of smoke. Upon interview, ES2 acknowledged the penetration.

2. At 12:50 p.m., the smoke barrier wall above the 90-minute fire barrier doors between the Lobby and the Acute side of the Hospital were observed. An approximately half-inch penetration was observed with low voltage wires running through it, in the smoke barrier wall. The penetration was not sealed to prevent the passage of smoke. Upon interview, ES2 acknowledged the penetration.

Based on observation and interview, the facility failed to the portable space heater. This was evidenced by the failure to follow manufacturer's directions on space heaters. This affected the nursing administration office and one of three smoke compartments and could result in an increased risk of fire.

Findings:

During a tour of the facility and interview with Maintenance Staff on 7/15/25, the space heaters were observed.

At 11:46 a.m., a portable space heater was observed under the Nutritionist's desk in the Nursing Administration Office. The space heater was plugged into an uninterruptable power supply. According to the manufacturer's instructions on a caution label on the portable space heater, the heater should be plugged directly into a wall electrical outlet. Upon interview, ES1 acknowledged that the space heater was not plugged into an electrical outlet.

Based on observation, record review and interview, the facility failed to maintain the operating room (OR) electrical system components. This was evidenced by the failure to provide testing records. This affected the OR and one of three smoke compartments and could result in an increased risk of an electrical malfunction in the OR.

NFPA 99 Health Care Facilities Code, 2012 edition
6.3.4.1.4 The LIM circuit shall be tested at intervals of not more
than 1 month by actuating the LIM test switch (see 6.3.2.6.3.6).
For a LIM circuit with automated self-test and self-calibration capabilities,
this test shall be performed at intervals of not more
than 12 months. Actuation of the test switch shall activate both
visual and audible alarm indicators.
6.3.4.1.5 After any repair or renovation to an electrical distribution
system, the LIM circuit shall be tested in accordance
with 6.3.3.3.2.
6.3.4.2 Record Keeping.
6.3.4.2.1* General.
6.3.4.2.1.1 A record shall be maintained of the tests required
by this chapter and associated repairs or modification.
6.3.4.2.1.2 At a minimum, the record shall contain the date,
the rooms or areas tested, and an indication of which items
have met, or have failed to meet, the performance requirements
of this chapter.

Findings:

During a tour of the facility, record review, and interview with Maintenance Staff on 7/15/25, the facility's electrical system components were observed, and maintenance records were requested.

At 3:46 p.m., the facility was observed with a line isolation monitor (LIM) located in the corridor outside of the OR suite. The test switch on the unit was actuated and nothing happened. The facility failed to provide testing records for the OR's line isolation monitor. Upon interview, ES1 stated that the OR had not been in used since January of 2025 and that he was not aware of the line isolation monitor testing requirements.

Based on record review and interview, the facility failed to provide continuing education to staff on oxygen cylinders handling procedures. This was evidenced by missing training records. This affected Patients that require oxygen and could result in staff mishandling oxygen equipment.

Findings:

During record review and interview with Respiratory Staff on 7/15/25, the oxygen cylinder training records were requested.

At 2:35 p.m., the facility failed to provide a record of a continuing education program that included safety guidelines and usage requirements for personnel concerned with the application, maintenance and handling of medical gases and cylinders. Upon interview, the Respiratory Staff acknowledged that there were no records available for review.