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Based on record review and interview, the facility failed to maintain the written emergency preparedness plan (EPP). This was evidenced by the failure to include a strategy for a risk assessment. This affected 21 of 21 Patients and could result in the facility not being prepared for an earthquake emergency.

Findings:

During record review and interview with the Quality/Risk Director on 1/18/24, the EPP was reviewed.

At 9:26 a.m., the facilities Hazardous Risk Assessment (HVA) listed earthquake as a risk for the facility. The EPP failed to include a strategy that addressed earthquakes. Upon interview, the Quality/Risk Director acknowledged that the EPP failed did not address earthquakes strategies.

Based on record review and interview, the facility failed to maintain the written emergency preparedness plan (EPP). This was evidenced by a communication plan that did not include vendor contact information. This affected 21 of 21 Patients and could result in a delay in response in the event of an emergency.

Findings:

During record review and interview with the Quality/Risk Director on 1/18/24, the emergency preparedness plan was reviewed.

At 10:04 a.m., the communication plan failed to include contact information for entities providing services under contract. There was no vendor contact information included in the communication plan. Upon interview, the Quality/Risk Director acknowledged that the facility was missing vendor contact information in their EPP.

Based on record review and interview, the facility failed to maintain the written emergency preparedness plan (EPP). This was evidenced by the failure to include contact information for emergency preparedness staff. This affected 21 of 21 Patients and could result in a delayed response to an emergency situation.

Findings:

During record review and interview with the Quality/Risk Director on 1/18/24, the emergency communication plan was reviewed.

At 10:06 a.m., the emergency preparedness plan failed to include contact information for Federal and State emergency preparedness staff. Upon interview, the Quality/Risk Director acknowledged that the communication plan was missing contact information.

Based on observation and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by a penetration in the ceiling. This affected one of nine smoke compartments and could result in the spread of smoke in the event of a fire.

Findings:

During a tour of the facility and interview with Maintenance Staff 1 on 1/17/24, the walls and ceilings were observed.

At 10:26 a.m., a one and a half inch by two-inch penetration was observed in the ceiling around a fire sprinkler in room 810. Upon interview, Maintenance Staff 1 acknowledged the penetration in the ceiling.

Based on observation and interview, the facility failed to maintain the hazardous area enclosures. This was evidenced by obstructed doors, doors that failed to latch and missing self-closing devices. This affected four of nine smoke compartments and could result in the spread of smoke and fire.

Findings:

During a tour of the facility with Maintenance Staff 1 on 1/17/24, the hazardous enclosure areas were observed.

1. At 10:14 a.m., the corridor door to room 702 failed to latch when tested. The door was equipped with a self-closing device and was tested three times. The room was approximately 400 square feet and contained shelves along all four walls that stored clean linens. Upon interview, Maintenance Staff 1 acknowledged that the door failed to latch.

2. At 10:21 a.m., the self-closing device on the corridor door to the Central Supply Room, room 800 was observed. The self-closing device was not functional and would not automatically close the corridor door. The room was approximately 450 square feet and was used to store non-medical related supplies for the hospital. Upon interview, Maintenance Staff 1 acknowledged that the door self-closing device was not working.

3. At 10:38 a.m., the corridor door to the purchasing Room, room 811 was observed missing a self-closing device. The room was approximately 300 square feet and stored cases of paper, cases of paper masks, cases of gloves and office supplies. Upon interview, Maintenance Staff 1 acknowledged that the corridor door was missing a self- closing device.

4. At 11:11 a.m., the North side corridor door to the Boiler Room in the 500 hall was tested. The door was a sliding metal-clad fire type door on a wall mounted incline track. When tested, the door failed to close all the way, leaving approximately six inches between the leading edge of the door and the frame. Upon interview, Maintenance Staff 1 acknowledged that the door failed to close all the way.

5. At 11:30 a.m., the door to storage room 513B was observed missing a self-closing device. The room was approximately 500 square feet and contained eight full shelved of paper medical records. Upon interview, Maintenance Staff 1 acknowledged that the door failed to close all the way.

6. At 1:16 p.m., the door to room 310A was observed missing a self-closing device. The room was approximately 120 square feet and contained shelves along the walls storing paper files with X-Ray records. Upon interview, Maintenance Staff 1 acknowledged that the door was missing a self-closing device.

Based on observation, record review and interview, the facility failed to maintain the kitchen hood fire suppression (Ansul) system. This was evidenced by the failure to provide one of two semiannual Ansul maintenance records. This affected one of nine smoke compartment and could result in the malfunction of the Ansul system.

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
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, 2011 Edition
11.2 Inspection, Testing, and Maintenance of Fire-Extinguishing Systems.
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 6 months.
11.2.8 Where required, certificates of inspection and maintenance shall be forwarded to the authority having jurisdiction.

Findings:

During a tour of the facility, record review and interview with Maintenance Staff 1 on 1/17/24, the kitchen Ansul system was observed, and records reviewed.

At 3:37 p.m., the facility failed to provide one of two semiannual kitchen hood fire suppression inspection and maintenance record within the last 12 months. The last inspection was dated 5/17/23. Upon interview, Maintenance staff 1 acknowledged the Ansul had only been inspected once within the last 12 months.

Based on observation, record review and interview, the facility failed to maintain the fire sprinklers. This was evidenced by foreign material on sprinklers and missing sprinkler gauge and valve inspection records. This affected 21 of 21 Patients and nine of nine smoke compartments and could result in the malfunction of the sprinklers in the event of a fire.

NFPA 101 Life Safety Code, 2012 edition
19.3.5.1 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
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, 2010 Edition
6.2.6.2 * Painting.
6.2.6.2.1 Sprinklers shall only be painted by the sprinkler manufacturer.
6.2.6.2.2 Where sprinklers have had paint applied by other than the sprinkler manufacturer, they shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition
4.1.1 * Responsibility for Inspection, Testing, Maintenance, and Impairment.
The property owner or designated representative shall be responsible for properly maintaining a water-based fire protection system.
5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).
5.2.4 Gauges.
5.2.4.1 * Gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.
13.3 Control Valves in Water-Based Fire Protection Systems.
13.3.2 Inspection.
13.3.2.1 All valves shall be inspected weekly.
13.3.2.1.1 Valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly.

Findings:

During a tour of the facility, record review and interview with Maintenance Staff 1 on 1/17/24, the automatic sprinkler system was observed, and records reviewed.

1. At 8:36 a.m., five of five sprinklers under the exterior overhang above the main lobby entrance were observed with foreign material on the frames and deflectors. Upon interview, Maintenance Staff 1 acknowledged that the sprinklers were covered in foreign material.

2. At 12:59 p.m., the single sprinkler head in the walk-in freezer was observed with foreign material on the frame, sensing bulb and deflector. Upon interview, Maintenance Staff 1 acknowledged that the sprinkler was covered in foreign material.

3. At 2:05 p.m., a sprinkler in the bathroom of room 105 was observed. Half of the deflector had been painted the same color as the ceiling. Upon interview, Maintenance Staff 1 acknowledged that the sprinkler had been painted.

4. At 3:48 p.m., the facility failed to provide fire sprinkler gauge and valve inspection records for 11 of the last 12 months. The only inspection record available for review was from December 2023. Upon interview, Maintenance Staff 1 stated that a staff had left in November 2023 and they were having trouble locating maintenance documentation.

Based on observation and interview, the facility failed to maintain the fire extinguishers. This was evidenced by a free-standing fire extinguisher. This affected one of nine smoke compartments and could result in an increased risk of damage to the fire extinguisher.

NFPA 101: Life Safety Code, 2012 Edition
19.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1
9.7.4.1 * Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10: Standard for Portable Fire Extinguishers, 2010 Edition
6.1.3 Placement.
6.1.3.1 Fire extinguishers shall be conspicuously located where they are readily accessible and immediately available in the event of fire.
6.1.3.4 * Portable fire extinguishers other than wheeled extinguishers shall be installed using any of the following means:
(1) Securely on a hanger intended for the extinguisher
(2) In the bracket supplied by the extinguisher manufacturer
(3) In a listed bracket approved for such purpose
(4) In cabinets or wall recesses

Findings:

During a tour of the facility and interview with Maintenance Staff 1 on 1/17/24, the fire extinguishers were observed.

At 12:45 p.m., a fire extinguisher was observed free standing on a shelf in Room 513C. Upon interview, Maintenance Staff 1 stated that it was mounted in the room but was moved and had not been permanently remounted.

Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by corridor doors that were obstructed from closing and corridor doors that failed to latch when tested. This affected five of nine 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 1 on 1/17/24, the corridor doors were tested.

1. At 9:27 a.m., the corridor door to the women's restroom in the lobby was observed held open by a wooden wedge. Upon interview, Maintenance Staff acknowledged that the door was held open by a wedge.

2. At 9:42 a.m., the corridor door to room 402 failed to latch when tested. The door was equipped with a self-closing device and was tested three times. Upon interview, Maintenance Staff 1 acknowledged that the door failed to latch.

3. At 9:59 a.m., the corridor door to room 714 failed to latch when tested. The door was equipped with a self-closing device and was tested three times. Upon interview, Maintenance Staff 1 acknowledged that the door failed to latch.

4. At 10:24 a.m., the corridor door to room 806 failed to latch when tested. The door was equipped with a self-closing device and was tested three times. Upon interview, Maintenance Staff 1 acknowledged that the door failed to latch.

5. At 10:34 a.m., the corridor door to room 815 failed to latch when tested. Upon interview, Maintenance Staff 1 stated that latching hardware for the door handle was missing preventing the door from latching.

6. At 10:39 a.m., the corridor door to room 811 failed to latch when tested. Upon interview, Maintenance Staff 1 stated that latching hardware for the door handle was missing preventing the door from latching.

7. At 2:03 p.m., the corridor door to room 109 was obstructed from closing by a walker. Upon interview, Maintenance Staff 1 acknowledged that the walker was obstructing the door from closing.

8. At 2:32 p.m., the corridor door to room 218 failed to latch when tested. Tape was observed on the latch bolt and strike plate that prevented the door from latching. Upon interview, Maintenance Staff 1 acknowledged the tape was preventing the door from latching.

Based on observation and interview, the facility failed to maintain the emergency gas shutoff valve. This was evidenced by the failure to have a means available for the shut of the gas valve. This affected 21 of 21 Patients and nine of nine smoke compartments and could result in a delay to shutting off the gas supply to the building in the event of an emergency.

NFPA 101 Life Safety Code, 2012 Edition
19.5.1 Utilities
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.
9.1 Utilities.
9.1.1 Gas.
Equipment using gas and related gas piping shall be in accordance with NFPA 54, National Fuel Gas Code, or NFPA 58, Liquefied Petroleum Gas Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 54, National Fuel Gas Code, 2012 Edition
7.9 Manual Gas Shutoff Valves.
7.9.2.3 Emergency Shutoff Valves. An exterior shutoff valve to permit turning off the gas supply to each building in an emergency shall be provided. The emergency shutoff valves shall be plainly marked as such and their locations posted as required by the authority having jurisdiction

Findings:

During a tour of the facility and interview with Maintenance Staff 1 on 1/17/24, the gas meter and shutoff valve was observed.

At 9:22 a.m., the gas meter and shutoff valve on the exterior of the 400 hall was observed. There was no wrench readily available to turn the gas valve off. Upon interview, Maintenance Staff 1 stated that they have a wrench in the shop but did not have it readily available.

Based on record review and interview, the facility failed to maintain the integrity of the heating, ventilation, and air-conditioning (HVAC) system. This was evidenced by deficiencies noted on their fire damper inspection report. This affected 21 of 21 Patients and nine of nine smoke compartments and could result in the spread of smoke in the event of a fire.

NFPA 101: Life Safety Code, 2012 Edition
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 Heating, Ventilating, and Air-Conditioning.
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
5.4.8 Maintenance.
5.4.8.1 Fire dampers and ceiling dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.

NFPA 80: Standard for Fire Doors and Other Opening Protectives, 2010 Edition
19.3.4 Documentation.
All inspections and testing shall be documented, indicating the location of the fire damper, date(s) of inspection, name of inspector, and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected.
19.4 * Periodic Inspection and Testing.
19.4.1.1 The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years.

Findings:

During record review and interview with Maintenance Staff 1 on 1/17/24, the fire dampers inspection records were reviewed.

At 4:14 p.m., a document labeled "Fire Damper Inspection Report" was reviewed. The inspection report indicated the fire dampers were inspected on 8/26/23 and had failed because of two missing fire dampers. Upon interview, Maintenance Staff 1 stated that they were not sure why the dampers were not replaced.

Based on record review and interview, the facility failed to maintain fire drills. This was evidenced by the failure to conduct 12 of 12 fire drills in the past 12 months. This affected 21 of 21 Patients and nine of nine smoke compartments and could result in staff being untrained and unaware of their roles and responsibilities in the event of a fire.

Findings:

During record review and interview with Maintenance Staff 1on 1/17/24, the fire drill records were reviewed.

At 11:39 a.m., the facility failed to provide documentation for an AM and a PM shift drills for the first quarter (January, February, March) of 2023, and the PM shift for the third quarter (July, August, September) of 2023. Upon interview, Maintenance Staff 1 acknowledged the missing fire drill records.

Based on observation and interview, the facility failed maintain portable space heaters. This was evidenced by the failure to follow manufacturer's directions and space heater plugged into power strips. This affected four of nine smoke compartments and could result in causing a fire.

Findings:

During a tour of the facility and interview with Maintenance Staff 1 on 1/17/24, the space heaters were observed.

1. At 9:31 a.m., a portable space heater was observed at the desk of the Referral Coordinator in room 406. The space heater was plugged into a power strip and was approximately three inches away from a cloth box containing clothes. 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 and no less than three feet from flammable furnishings. Upon interview, Maintenance Staff 1 acknowledged that the space heater was plugged into a power strip and less than three feet away from flammable furnishings.

2. 10:10 a.m., a portable space heater was observed in the Radiology Managers Office, room 704. The space heater was plugged into a wall outlet and was less than three feet away from a printer, desk and wall of the room. According to the manufacturer's instructions on a caution label on the portable space heater, the heater should be no less than three feet from flammable furnishings. Upon interview, Maintenance Staff 1 acknowledged that the space heater was less than three feet away from flammable furnishings.

3. At 10:33 a.m., a portable space heater was observed in room 815. The space heater was plugged into a power strip. 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, Maintenance Staff 1 acknowledged that the space heater was plugged into a power strip.

4. At 1:46 p.m., two portable space heaters were observed in the Doctors Sleep Lounge, room 339. The first space heater was approximately three inches away from a garbage can and the second space heater was plugged into a power strip. According to the manufacturer's instructions on a caution label on both portable space heaters, the heaters should be plugged directly into a wall electrical outlet and no less than three feet from flammable furnishings. Upon interview, Maintenance Staff 1 acknowledged that the space heaters were plugged into a power strip and less than three feet away from flammable furnishings.

Based on observation, and interview, the facility failed to maintain the emergency power supply system (EPSS). This was evidenced by the failure to provide a permanent working emergency backup generator. This affected 21 of 21 Patients and nine of nine smoke compartments and could result in a loss of power due to a generator malfunction during an emergency power outage.

NFPA 99, Health Care Facilities Code, 2012 Edition.
6.4 Essential Electrical System Requirements - Type 1.
6.4.4.1.3 Maintenance of Batteries. Batteries for on-site generators shall be maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition.
4.4.3 All equipment shall be permanently installed.

Findings:

During a tour of the facility, and interview with Maintenance Staff 1 on 1/17/24, the EPSS was observed.

At 8:36 a.m., a temporary trailer mounted 200-Kilowatt (KW) diesel generator was observed onsite and was connected to the automatic transfer switch (ATS). The temporary generator was located on the North side of the building and was stationed on a wheeled platform, protected by concrete parking barriers, and was secured to the barriers by metal cables. A new diesel generator was observed onsite, outside of the 500 hall, not connected. The facility was in the process of replacing the old failed generator with the new diesel generator onsite. Upon interview, Maintenance Staff 1 stated that the temporary generator has been in use for approximately three to four years.

Based on observation and interview, the facility failed to maintain the electrical equipment. This was evidenced by the use of extension cords, daisy chained and suspended power strips. This affected three of nine smoke compartments and could result in causing a fire.

NFPA 101 Life Safety Code, 2012 Edition
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.
9.1 Utilities.
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
(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
400.10 Pull at Joints and Terminals. Flexible cords and cables shall be connected to devices and to fittings so that tension is not transmitted to joints or terminals. Exception: Listed portable single-pole devices that are intended to accommodate such tension at their terminals shall be permitted to be used with single-conductor flexible cable.

Findings:

During a tour of the facility and interview with Maintenance Staff 1 on 1/17/24, the electrical equipment was observed.

1. At 9:58 a.m., an orange extension cord was observed powering a power strip in room 714. The extension cord was plugged into another power strip that was plugged into a wall outlet. Upon interview, Maintenance Staff 1 acknowledged the extension cord.

2. At 10:07 a.m., a white power strip was observed suspended approximately three inches above the floor in the Workers Compensation office, room 706. The power strip was next to a two-drawer file cabinet and was suspended by the power cord to a coffee maker that was on top of the cabinet. Upon interview, Maintenance Staff 1 acknowledged the suspended power strip.

3. At 1:08 p.m., a power strip was observed suspended approximately three inches above the floor in room 301. The power strip was next to a small refrigerator and was suspended by the power cord to a microwave that was on top of the refrigerator. Upon interview, Maintenance Staff 1 acknowledged the suspended power strip.

4. At 2:11 p.m., a power strip was observed daisy chained to an uninterrupted Power Supply type power strip under the Infection Control desk in the infection control/Activities office, room 201. The power strip was powering computer and phone equipment. Upon interview, Maintenance Staff 1 acknowledged the daisy chained power strips.

Based on observation and interview, the facility failed to maintain the oxygen cylinder storage. This was evidenced by full and empty oxygen tanks that were not segregated, and a free-standing tank that was not secured. This affected the outdoor oxygen tank storage area and could result in confusion or delay if a full cylinder is needed in a rapid manner and the increased risk of fire.

NFPA 99: Health Care Facilities Code, 2012 Edition
11.3 Cylinder and Container Storage Requirements.
11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures:
(1)Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device.
(2)Oxygen cylinders shall not be stored near elevators or gangways or in locations where heavy moving objects will strike them or fall on them.
(3)Cylinders shall be protected from tampering by unauthorized individuals.
(4)Cylinders or cylinder valves shall not be repaired, painted, or altered.
(5)Safety relief devices in valves or cylinders shall not be tampered with.
(6)Valve outlets clogged with ice shall be thawed with warm - not boiling - water.
(7)A torch flame shall not be permitted, under any circumstances, to come in contact with a cylinder, cylinder valve, or safety device.
(8)Sparks and flame shall be kept away from cylinders.
(9)Even if they are considered to be empty, cylinders shall not be used as rollers, supports, or for any purpose other than that for which the supplier intended them.
(10)Large cylinders (exceeding size E) and containers larger than 45 kg (100 lb) weight shall be transported on a proper hand truck or cart complying with 11.4.3.1.
(11)Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.
(12)Cylinders shall not be supported by radiators, steam pipes, or heat ducts.
11.6.5 Special Precautions - Storage of Cylinders and Containers.
11.6.5.1 Storage shall be planned so that cylinders can be used in the order in which they are received from the supplier.
11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders.
11.6.5.3 Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner.

Findings:

During a tour of the facility and interview with Maintenance Staff 1 on 1/17/24, the oxygen storage was observed.

1. At 9:04 a.m., the oxygen storage cage on the exterior of the 300 hall was observed. There were approximately 48 E type oxygen tanks stored in the cage. Approximately two empty E tanks were observed mingled together with the full E tanks. There was no signage indicating which area to store full and empty tanks. Upon interview, Maintenance Staff 1 acknowledged that the E tanks were not segregated in the cage.

2. At 9:40 a.m., a free-standing E type oxygen tank was observed in the Cardiopulmonary Room, room 402. The tank was under a table and against the wall. Upon interview, Maintenance Staff 1 acknowledged that the tank was free standing.