Other·August 12, 2022

42CFR §483.90(i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. 22CCR § 72521 Administrative Policies and Procedures. (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. On 6/28/2022, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint and a facility-reported incident (FRI) about a fire in the facility. The facility failed to provide a safe environment for all 96 residents in the facility, staff, and visitors, by failing to: 1. Obtain required written authorization, building permits, or attain construction approval for the renovations/alterations in one of four public restrooms [Restroom 2 (outpatient rehabilitation restroom)] from the Department of Healthcare Access and Information [HCAI, previously known as the Office of Statewide Health Planning and Development or (OSHPD)]. Unauthorized alteration/construction included the installation of a domestic-type ceiling exhaust fan, missing fire damper protection, installation of flexible metal duct connector, installation of non-fire rated ceiling assembly, and a restroom expansion as evidenced by sprinkler separation issues. A fire damper is designed to close automatically upon detection of heat (such as a fusible link or heat detector) and to interrupt airflow and to restrict the passage of fire. Fire resistant or fire resistance-rated refers to the fire ratings of the building's floors, wall, and ceilings. Fire resistant or fire resistance-rated walls, floors, and/or ceilings are intended to contain a fire inside that smoke compartment and prevent it from spreading for a period of time. HCAI is the State agency that reviews and approves plans for construction, repairs, renovations, and remodeling made to healthcare facilities to comply with State Building Codes. 2. Obtain required written authorization, building permits, and attain construction approval for two of four additional public restrooms [Restroom 1 (lobby restroom) and Restroom 3 (public restroom near the Social Services office) regarding similar non-compliant HCAI alterations/construction issues, including the installation of an exhaust fan appliance and missing fire damper protection. 3. Ensure exhaust fans in four of four public restrooms were maintained and maintenance records were retained in the facility. 4. Obtain required written authorization, building permits, and attain construction approval for the alterations in the facility's roof-ceiling assembly from HCAI. 5. Notify the Department in writing within five days of the commencement of any construction, remodeling, or alterations. As a result, on 6/28/2022, at 4:28 a.m., fire erupted in Restroom 2. On 6/28/2022, at 9:22 a.m., during an interview, the Maintenance Director (MD) stated he received a telephone call from one of the staff notifying him of a fire in a restroom. The fire alarm activated, and a staff activated the manual pull station next to Room 115. The fire originated in the outpatient rehabilitation restroom (Restroom 2 as identified by the Nurse Call dome light). On 6/28/2022, at 9:40 a.m., during an interview and concurrent observation of Restroom 2 with MD, the evaluator observed black residue on the door, walls, ceiling, floor, and restroom fixtures from the fire incident. There was a hole on the ceiling exposing the grille housing, metal duct connector, electrical connections, and wooden construction of the roof-ceiling assembly. The MD explained the Fire Department responded to the fire and removed the exhaust fan and part of the ceiling construction. The cause of the fire was due to the exhaust fan motor getting stuck and overheating and was likely an electric fire. The MD stated it was the maintenance department's responsibility to clean/maintain restroom exhaust fans. On 6/28/2022, at 9:48 a.m., during an interview and concurrent observation outside the facility, the evaluator observed the burnt exhaust fan motor, the exhaust fan blower wheel, and parts of the ceiling construction that were removed from Restroom 2. The burnt fan motor and the "blower wheel" had a buildup of dust/dirt/lint and black residue from the fire. The MD demonstrated that the fan motor was hard to turn and explained, "you can feel if the motor is in good condition, it rotates well". The MD stated the exhaust fan was installed "years ago" but did not remember the exact date. On 6/28/2022, at 10:15 a.m., during an interview, the Administrator (ADM) stated at 4:30 a.m., staff found smoke seeping through the top opening of Restroom 2's door while the door was in a closed position. At 4:35 a.m. on 6/28/2022, the Registered Nurse (RN) Supervisor along with Licensed Vocational Nurse 2 (LVN 2) decided to evacuate residents closest to the fire. At 4:38 a.m. on 6/28/2022, the Fire Department arrived at the facility. The ADM added, there was a live fire in the ceiling above the exhaust fan motor. During a record review of the Central Monitoring Station Activity Report, dated 6/28/2022, the document indicated the following: a. At 4:30 a.m., the smoke detector activated outside the physical therapy room activating the fire alarm system b. At 4:33 a.m., call to Fire Department for dispatch b. At 4:34 a.m., the manual pull alarm was activated outside room 115 c. At 4:41 a.m., the smoke detector activated at the lobby area d. At 4:42 a.m., the smoke detector activated at the fire alarm control panel (FACP) On 6/28/2022, at 10:38 a.m., during a review of the "Semi Annual - HVAC (heating, ventilation, and air conditioning) Duct and Damper PM" cleaning log and a concurrent interview with the MD, Restrooms 1 (lobby restroom), 2 (outpatient rehabilitation restroom), 3 (restroom next to Social Services office), 4 (another restroom next to Social Services office) were not included in the cleaning log. The MD confirmed that public restrooms 1 to 4 were not included in the log. The MD asserted the cleaning of restroom exhaust fans occurs every 6 months, but the maintenance/cleaning of exhaust fans in the restrooms was not being documented. On 6/28/2022, at 11:42 a.m., during a concurrent observation and interview with the MD outside the facility, the MD confirmed formation of dust/dirt/lint on the burnt exhaust fan motor and fan blower wheel. The MD stated the exhaust fan suctions air out day and night and that the exhaust fan was running continuously. On 6/28/2022, at 12:23 p.m., during an interview, LVN 1 stated she was working in the facility when the fire occurred. She saw smoke on the ceiling along the hallway which got heavier around the time the Fire Department arrived. LVN 1 stated that residents in Rooms 201 to 213 were evacuated to the facility parking lot. On 6/28/2022, at 12:44 p.m., during an interview, LVN 2 stated that she was working when the fire occurred and was assigned to rooms 201 to 213. LVN 2 explained that when the fire alarm activated, she went to locate the fire and saw white smoke coming from Restroom 2. The smoke from Restroom 2 turned from white to black. There was smoke on the ceiling along the hallway and that the smoke was spreading. LVN 2 stated, she was worried for the safety of the resident in room 202, the closest room to the fire, since the resident was connected to an oxygen machine. LVN 2 added, there were other residents connected to oxygen machines and LVN 2 and the RN Supervisor decided to evacuate residents starting from the hallway where the fire occurred. On 6/28/2022, at 1:28 p.m., during a review of the "Semi-Annual HVAC Duct and Damper PM Procedures" and concurrent interview with the MD, the document included the following procedures: a. Turn off air conditioner unit to be worked on b. Clean supply, return and exhaust grills, and c. Clean fire damper and air duct. The MD confirmed the "Semi-Annual HVAC Duct and Damper PM Procedures" did not include procedures for cleaning and maintenance of exhaust fans in the public restrooms. The MD stated cleaning of exhaust fans did not involve air conditioning shut off and the maintenance department did not have other procedures for cleaning and maintenance of exhaust fans. The MD agreed the public restrooms were not included on the "Semi Annual - HVAC Duct and Damper PM" cleaning log as it was not connected to an air conditioning unit. The MD explained the purpose of a fire damper, in case of fire, is for the fusible link to automatically closes the damper blades, preventing fire/smoke from spreading. On 6/28/2022, at 1:59 p.m., during an interview, the Maintenance Assistant (MA) stated he cleaned the exhaust fan motor, housing, and the fan blower wheel the morning of 6/28/2022 in Restroom # 1, 3 and 4, following the fire, and observed a buildup of dust/dirt on the exhaust fan motor in Restroom 1 and smoke residue on the appliance. A review of the facility's Incident Report, dated 6/28/2022, indicated residents in Rooms 201, 202, 203, 204, 205, 206, 207, 209, 211, and 213 were evacuated to the rear parking area due to the fire emergency. There was a total of 20 residents that were temporarily evacuated. Fire fighters arrived at the facility at 4:38 a.m. and identified the source of the black smoke the exhaust fan motor in the restroom (Restroom 2). The fan motor in the restroom overheated. On 6/29/2022, at 10:28 a.m., during a concurrent observation and interview with HCAI's Fire Marshal (FM) and the MD, in Restroom 2, the FM and the evaluator observed a metal duct on the ceiling opening, exhaust fan housing, and two sprinklers installed on the restroom ceiling. The FM explained the exhaust fan was missing a fire damper protection and the exhaust fan and metal duct connector were installed without approval from HCAI. The FM added, sprinklers were required to be at least six feet apart. The FM proceeded to measure the distance between the sprinkler heads in Restroom 2, obtaining a measurement of 5 ½ feet. The FM stated that due to the size of the room, only one sprinkler head was required. The FM also stated the ceiling drywall appeared to be thinner than the required fire rated assembly. The MD stated he had been working in the facility for 16 years and in that area of the facility, there used to be a storage room and two smaller restrooms prior to being converted into Restrooms 1 and 2. The FM determined Restroom 2 was renovated/altered without approval/authorization from HCAI. On 6/29/2022, at 10:50 a.m., during a concurrent observation and interview with the FM, ADM, and MD, in Restroom 1, the FM and the evaluator observed a newer exhaust fan appliance installed on the ceiling. The FM explained the facility installed a newer exhaust fan appliance which was missing a fire damper protection. The FM added, the exhaust fan appliance was installed without approval/authorization from HCAI. On 6/29/2022, at 10:54 a.m., during a concurrent observation and interview with the FM, ADM, and MD, in Restroom 3, the FM and the evaluator observed an exhaust fan appliance installed on the ceiling. The FM explained the exhaust fan motor appeared to be newer and that the opening on the ceiling was missing a fire damper protection. The FM stated the exhaust fan motor was installed without approval/authorization from HCAI. On 6/29/2022, at 11:02 a.m., during an interview, the FM stated facilities are required to obtain authorization/approval from HCAI prior to commencing work on the building's fire resistive assemblies. The FM explained the fire resistive assembly includes the ceiling throughout the facility, as it is rated construction. On 6/29/2022, at 11:32 a.m., during a concurrent observation and interview with the FM and the MD, the MD pointed at the location of the electrical panels in Nursing Station 2 (electrical panel houses circuit breakers that control electricity to different parts of the building. A circuit breaker is a device designed to automatically shut off when there is too much electrical current running through them, preventing overloading). The FM examined the circuit breakers on the facility's electrical panels and based on the labeling on the electrical panel, Restrooms 1 and 2 were powered by the same 20 amperes electrical circuit. The FM also stated that it appeared that none of the circuit breakers "tripped" (shut off) and that the circuit breaker should have tripped when the exhaust fan motor started drawing too much power, resulting in the fan motor overheating. On 6/29/2022, at 11:40 a.m., during an interview with the FM and the ADM, the FM stated the facility removed the fire resistive ceiling without approval/authorization from HCAI. The ADM confirmed the ceiling was altered. On 6/29/2022, at 11:58 a.m., during an interview, the FM stated Restrooms 1, 2, and 3 had installations/alterations/construction without authorization/approval from HCAI and due to unapproved installations/alterations/construction in these public restrooms, there was a potential of fire erupting. FM also questioned the accuracy of appliances and the electricals installation as they were installed without the benefit of review/approval from HCAI. According to HCAI's Regional Compliance Officer 1 (RCO 1) correspondence with the ADM, dated 6/28/2022, RCO 1 indicated the ceiling in Restroom 2 appeared to be a single layer and, as such, was not code compliant. A review of HCAI's Construction Advisory Report titled, "Restroom Fire Investigation from Exhaust Fan Fire the morning of 6/28/2022", dated 6/29/2022, authored by the HCAI's FM, indicated an investigation of reported unauthorized construction was conducted on 6/29/2022 and the following was noted: a. The fire originated in Restroom 2 at a ceiling exhaust fan which appeared to have been running continuously and subsequently overheated. The responding agency removed the appliance and approximately 2 feet by 3 feet of the bottom membrane of the horizontal roof-ceiling assembly. Water and smoke damage was observed within the room and roof cavity. b. Restroom 2 and adjacent restroom (Restroom 1) appeared to have been renovated and/or altered without required authorization or approvals from HCAI as evidenced by: 1. The domestic-type ceiling exhaust fan was missing required fire damper protection 2. Fire sprinklers in the restroom were observed less than six feet apart. Due to the size of the room, only one fire sprinkler head would be required. 3. A flexible metal duct connector was observed installed in lieu of a metal exhaust duct. The connector was observed with apparent dust/debris build-up as well. 4. Both adjacent restrooms lighting, exhaust fans, receptacles and corridor receptacles appeared to be powered by the same 20 amperes electrical circuit. The exhaust fans should be provided with independent or individual circuits. Also, the electrical conductors appeared to be installed only in flexible metal conduit. Use of "Flexible Metal Conduit" is limited to lengths not in excess of 6 feet. On 6/29/2022, at 1:26 p.m., the evaluator requested the ADM a copy of any building permits/final construction sign-off approvals from HCAI for the installation/alterations and construction in the facility's public restrooms. There were none provided to the evaluator. On 6/30/2022, at 9:46 a.m., during an interview, FM confirmed that without required fire damper protection on the ceiling openings in Restrooms 1 and 3, there was a likelihood that a fire could spread through the facility. The FM added, the facility also removed the fire resistive ceiling along the exit access corridor which also increases the likelihood of fire spreading to other parts of the facility. During an interview with the ADM on 6/30/2022, at 12:13 p.m., the ADM stated that he started working in the facility in 2015. He was made aware of unauthorized work in the facility including the alteration of the facility's roof-ceiling assembly. The ADM stated that the roof-ceiling assembly was replaced with non-fire rated ceiling tiles. The ceiling tiles and its framing throughout the facility corridors were installed without approval/a