HospitalInspections.org

Based on observation and interviews, the facility failed to maintain construction, protection, and occupancy features necessary to minimize danger to life from smoke, fumes or panic should a fire or similar emergency occur. The facility failed to maintain existing fire protection and life safety features such as smoke compartments and smoke construction per NFPA 101-2000 , 4.6.12.1-.4 "Features required by the Code...shall be thereafter permanently maintained." Two (2) out of 8 sampled smoke compartments had unsealed penetrations.
Findings include:
During the survey inspection on June 7, 2010 with Safety management Manger, observed that this requirement was not met as evidenced in the following locations:

At 3:54 p.m. on the first floor, observed in the electrical room that 1/4 inch plywood backing with no fire rating had been used on the wall to support installations of electrical components.

On June 8, 2010 at 11:56 a.m. on the third floor, observed in the network 'K' room that plywood had been installed with no fire rating to support network components.

Based on observations, testing and interviews with facility staff, the facility failed to maintain fire protection and occupancy features necessary to minimize danger to residents from smoke, fumes or panic should a fire occur. The facility did not maintain a set of automatic / self closing fire rated doors so they were operable after activation of the fire alarm system. NFPA 101-2000, 4.6.12.1 requires that "every...item of equipment / system required by this Code shall be continuously maintained in proper operating condition." These doors had an impediment to closing them so they would not limit the transfer of smoke should a fire occur. Seven (7) doors out of 20 plus tested sets of fire / smoke doors were so affected.

Findings are:

During the survey inspection on June 7, 2010 with Safety management Manger, observed that this requirement was not met as evidenced in the following locations:

1. At 3:11 p.m. on the first floor, observed NAMI closet rated door propped open.

2. At 4:04 p.m. on the first floor, observed Storage room, discovered two wooden wedges holding open a rated door.

3. At 4:07 p.m. on the first floor, observed in corridor held open with a friction type device at the floor level, this were not connected to a magnetic device or tied into the fire alarm system.

4. At 4:20 p.m. on the first floor, observed two leaf type doors in an eight foot corridor with one having a carriage type lock installed to prevent entry or access from one direction.

5. On June 8, 2010 at 9:32 a.m., therapist room observed the door to be blocked from opening 90 degrees.

6. On the second floor at 11:38 a.m., observed janitors closet door to be blocked from opening 90 degrees.

7. On the third floor at 11:56 a.m., observed network 'K' room with door blocked open with debris.

Based on observation and interview, the facility failed to comply with exit sign requirements. Per NFPA 1-97, 4-7 ... "Exits shall be marked by an approved sign readily visible from any direction of exit access." Failure to maintain these lighted directional signs could lead to confusion and possibly panic should an emergency evacuation (horizontal exiting) become necessary.

Findings are:

During the survey inspection on June 7, 2010 with Safety management Manger, observed that this requirement was not met as evidenced in the following locations. On the first floor at 4:46 p.m. in STAR corridor, observed exits sign facing the wrong direction (out).

Based on interviews about fire / emergency drills with facility staff, the facility did not provide effective evidence that fire drills are held under varying conditions (scenarios), at least quarterly on each shift for the laboratory. Therefore, the facility did not ensure that all laboratory staff were familiar with varying aspects of the emergency procedures. Per 19.7.1.2, "Employees of health care facilities shall be instructed in life safety procedures and devices." Staff needs to be prepared to execute their duties during all emergency situations / scenarios.

Findings:


Based on observations and record review, no documentation was recorded to prove that on the first quarter of 2010 for the third shift had participated in any fire drills. Documentation demonstrated that four months had lapsed from December 2009 until April 2010 for a fire drill to be performed.

Based on observations and interviews with staff members, determined that the facility did not maintain protection per NFPA 101-2000, 4.6.12.1 requires that 'every...item of equipment / system required by this Code shall be continuously maintained in proper operating condition'.

Findings:

During the survey inspection on June 7, 2010 with Safety management Manger, observed that this requirement was not met as evidenced in the following locations. On the first floor at 3:38 p.m. in medical records, observed smoke detector incorrectly installed incorrectly on the ceiling tile. It was installed less than 4 inches from the wall in an area that would cause air turbulence in case of smoke and affect its operation per manufacturer installation requirements.

Based on observations, record review and interviews, the facility did not maintain sprinkler piping and fittings per NFPA 101-2000, 9.7.5 requires that "all automatic sprinkler systems required by this Code shall be continuously maintained in reliable operating condition at all times. . . ." and per NFPA 25, 2-4.1.8. Some areas had fire sprinkler heads with missing / loose escutcheon rings. Four (4) of eight smoke compartments sampled were so affected.

Findings:

During the survey inspection on June 7, 2010 with Safety management Manger, observed that this requirement was not MET as evidenced in the following locations:

On the first floor
1. at 3:17 p.m. in NAMI closet, observed broken ceiling tiles that would affect fire sprinkler performance.

2. at 3:33 p.m. in medical records, observed Fire sprinkler with damaged escutcheon plate, also 6 of 10 fire sprinklers were covered in dust and debris which could affect the effectiveness of activation of the sprinklers in case of a fire.

3. at 3: 47 p.m. in main conference storage, observed missing ceiling tiles that would affect fire sprinkler activation in case of a fire.

4. at 3: 48 p.m. in Princeton conference room storage, observed missing ceiling tiles that would affect fire sprinkler activation in case of a fire, also fire sprinkler blocked by light fixture, needs extended head.

5. at 4:02 p.m. in environmental room, observed missing ceiling tiles that would affect fire sprinkler activation in case of a fire.

6. at 4:40 p.m. in STAR corridor, observed fire sprinkler missing escutcheon plate.

7. at 5:11 p.m. in file storage room, observed 18 inch rule not being adhered to.

On June 8, 2010
8. at 9:32 a.m. in COP therapist room, observed in adequate protection due to columns 16 inches by 16 inches blocking spray patter from fire sprinkler (class 'A' flammables).

9. at 9:43 a.m. on network closet, observed missing ceiling tiles that would affect fire sprinkler activation in case of a fire.

10. at 9:56 a.m. in CRC hall mop room, observed fire sprinkler escutcheon plate broken and ceiling tiles with large gaps.

11. at 10 a.m. in CRC client lounge, observed fire sprinkler with missing escutcheon plate.

12. at 10:18 a.m. in CRC electrical room, observed ceiling tiles with large open gaps affecting fire sprinkler performance.

13. at 10:41 a.m. in Pharmacy, observed solid shelving 9 inches from the ceiling affecting fire sprinkler performance.

Second Floor
14. at 11:42 a.m. in STARS area observed open ceiling tiles affecting fire sprinkler performance.

Third Floor
15. at 11:56 a.m. in network 'K' room observed open ceiling tiles affecting fire sprinkler performance.

16. at 12:18 p.m. in 3 clothing storage rooms observed open ceiling tiles affecting fire sprinkler performance.

Fourth Floor
17. at 12:25 p.m. in dumb waiter room observed open ceiling tiles affecting fire sprinkler performance.

Based on observation, the facility failed to maintain fire extinguishers as required. The deficient practice affected three out of 8 smoke compartments.

Findings:

During the survey inspection on June 7, 2010 with Safety management Manger, observed that this requirement was not met as evidenced in the following locations:

On the first floor
1. at 3:44 p.m. in case management office, observed missing fire extinguisher in hose cabinet number 34.

On June 8, 2010
2. at 9:48 a.m. in CMC (children's medical clinic), observed fire extinguisher in need of recharge.

Third Floor
3. at 12:02 p.m. at 3 east stair well, observed missing fire extinguisher.

Based on observations, interviews and testing, the facility failed to maintain the ventilation system equipment in accordance with NFPA 90A and with NFPA 101-2000, 4.6.12.4, "every...item of equipment required by this Code shall be continuously maintained in proper operating condition." Little or no ceiling exhaust ventilation (exchange of air) when tested observed in three (3) of 8 sampled smoke zones were so affected.

Findings:

During the survey inspection on June 8, 2010 with Safety management Manger, observed that this requirement was not met as evidenced in the following locations:

1. at 9:53 a.m. in CRC hall mop closet, observed exhaust vent clogged.

Second Floor
2. at 11:42 a.m. in OB number 6, observed ceiling air condition vent was not secure in danger of falling.

Fourth Floor
3. at 12:34 p.m. in Kitchen (small room) exhaust not working (refrigerator and ice maker) in room.

Based on an observation and interviews, the facility failed to maintain construction, protection, and occupancy features necessary to minimize danger to life from smoke, fumes or panic should a fire or similar emergency occur. The facility failed to maintain existing fire protection and life safety features such as smoke compartments and smoke construction per NFPA 101-2000 , 4.6.12.1-.4 "Features required by the Code...shall be thereafter permanently maintained." Five (5) out of 15 sampled smoke compartments had unsealed penetrations.
Findings include:
During the survey inspection on June 7, 2010 with Safety management Manger, observed that this requirement was not met as evidenced in the following locations:

1. at 3:18 p.m. corridors, observed several fire alarm devices had been removed from walls and ceilings leaving open gaps in rated walls. Devices had been removed due to recent approved changed in the fire alarm system. The openings in the rated walls and ceiling have created a hindrance to the effective protection of the rated fire walls and smoke compartments. Safety Manger explained they are diligently addressing the situation in repairing the open penetrations through the facility.

2. at 3:18 p.m. corridor rated fire doors, observed penetrations above the door not protected.

3. at 3:54 p.m. electrical room, observed penetrations in rated wall.

4. at 4:02 p.m. environmental room, observed penetrations on the smoke wall

5. at 4:43 p.m. in STAR corridor electrical room, observed pipe penetrations in rated wall

On June 8, 2010
6. at 9:43 a.m. in Network closet, observed a 2 inch hole in the 1 hr rated wall.

7. at 10:51 a.m. in purchasing storage, observed penetration in rated wall not protected.

Second Floor
8. at 11:43 a.m. in North electrical room, observed penetrations in rated wall and mixing of fire caulks.

Third Floor
9. at 11:56 a.m. in network room, observed penetrations in rated wall.

10. at 12:09 p.m. in electrical room, observed penetrations in rated wall.

Based on observations and interviews with facility staff, determined that the facility did not maintain the following per the Code (NFPA 101-2000) and NFPA 99. The facility failed to maintain fire protection and occupancy features necessary to minimize danger to life. This includes not ensuring that auxiliary areas, (i.e., boiler room, etc.), were free of hazardous conditions. Also, they failed to maintain the required occupancy features per NFPA 101-2000, 19.7.5 & 10.3.5, storage of a material of a "'highly flammable character shall not be used.".

Findings:

At 3:20 on June 7, 2010 with Safety management Manger, observed that the stored compressed oxygen and acetylene tanks were stored in unsafe conditions. They were within twelve inches from a critical reset button that controlled pumps to the building.

Based on an observation and interviews with facility staff, the facility did not maintain the following per the National Electric Code (NEC); Article 517 and NFPA 99. The facility failed to maintain fire protection and occupancy features necessary to minimize danger to life. Use of temporary wiring for a high amperage / motorized device did not demonstrate compliance with the code standard. Twenty (20) out of 60 plus electrical devices sampled did not operate as required or did not meet with hospital standards.

Findings:

During the survey inspection on June 7, 2010 with Safety management Manger, observed that this requirement was not met as evidenced in the following locations:

1. at 3:11 p.m. in safety management manager office, observed a multi tap adapter with refrigerator and microwave plugged into it, surpassing its rated capacity.

2. at 3:30 p.m. in CFO restroom, observed florescent lamp missing protective lens cover.

3. at 3:33 p.m. in medical records, observed 1) electrical extension cord pinched by base board supplying computers, extension cords are for 30 day temporary use and danger of electrical fire due to incorrect placement of cord. 2) Refrigerator plugged into surge protector surpassing its rated capacity.

4. at 3:48 p.m. in Princeton conference room, storage observed florescent fixture with no lamp cover.

5. at 3:54 p.m. in electrical room, observed 1) electrical panels (LNAB, LCAB, LCA) with open spaces and breakers not identified. 2) Florescent lamp with no protective lens cover.

6. at 4:02 p.m. in environmental service, observed florescent lamp missing protective lens cover.

7. at 4:07 p.m. in nurse station, observed electrical surge protector hanging from cord end.

8. at 4:10 p.m. in nurse station office, observed orange electrical extension cord used as permanent supply, extension cords are to be used for 30 day temporary use only.

9. at 5:13 p.m. in electrical room, observed 1) electrical panels (LCAC, LNAC, LCX) with open spaces. 2) Florescent lamp missing protective lens cover.

On June 8, 2010
10. at 9:04 a.m. in Residential clinical manager, office observed surge protector hanging from cord end.

11. at 10:04 a.m. in CRC business office, observed daisy chained surge protectors (plugged into one another).

12. at 10:18 a.m. in CRC copy room, observed refrigerator plugged into surge protector, surpassing rated capacity of device.

13. at 10:36 a.m. in schedule room, observed power tap in use

14. at 10:47 in pharmacy break room, observed refrigerator plugged into surge protector, surpassing its rated capacity.

15. at 10:51 in pharmacy storage, observed over 20 florescent fixtures with no protective lens covers.

Second Floor
16. at 11:24 a.m. in Pharmacy, observed refrigerator plugged into surge protector, surpassing rated its rated capacity.

Third Floor
17. at 11:53 a.m. in Lounge, observed orange extension cord in use as permanent supply, only to be used as temporary 30 day use.

18. at 11:54 a.m. in payroll, observed extension cord used as permanent power supply, only to be used as temporary 30 day use.

Fifth Floor Penthouse
19. at 12:50 p.m., electrical panels (LPN) no panel schedule and open electrical openings in junction box.

Based on observations and interviews with facility staff, the facility did not maintain the following per the Code: (NFPA 101-2000 and NFPA 99-1999). The facility failed to maintain fire protection and occupancy features necessary to minimize danger to life. This includes not ensuring that patient areas were free of hazardous conditions. Also, they failed to maintain the required occupancy features per 19.3.2.6, "Alcohol Based Hand Rub (ABHR) dispensers are properly installed (not over or adjacent to an electrical ignition sources)." Nine (9) of 30 plus units observed had improperly installed dispensers.

Findings are:

During the survey inspection on June 8, 2010 with Safety management Manger, observed that this requirement was not met as evidenced in the following locations:

1. at 10:04 a.m. in Children's Medical clinic business office, observed alcohol hand rub dispenser installed directly over electrical source.

Second Floor
2. at 11:43 a.m. in nurse station, observed alcohol hand rub dispenser installed directly over electrical source.

Fourth Floor
3. at 12:23 p.m. in activity therapist room, observed alcohol hand rub dispenser installed directly over electrical source.

Based on observation and interviews, the facility failed to maintain construction, protection, and occupancy features necessary to minimize danger to life from smoke, fumes or panic should a fire or similar emergency occur. The facility failed to maintain existing fire protection and life safety features such as smoke compartments and smoke construction per NFPA 101-2000 , 4.6.12.1-.4 "Features required by the Code...shall be thereafter permanently maintained." Two (2) out of 8 sampled smoke compartments had unsealed penetrations.
Findings include:
During the survey inspection on June 7, 2010 with Safety management Manger, observed that this requirement was not met as evidenced in the following locations:

At 3:54 p.m. on the first floor, observed in the electrical room that 1/4 inch plywood backing with no fire rating had been used on the wall to support installations of electrical components.

On June 8, 2010 at 11:56 a.m. on the third floor, observed in the network 'K' room that plywood had been installed with no fire rating to support network components.

Based on observations, testing and interviews with facility staff, the facility failed to maintain fire protection and occupancy features necessary to minimize danger to residents from smoke, fumes or panic should a fire occur. The facility did not maintain a set of automatic / self closing fire rated doors so they were operable after activation of the fire alarm system. NFPA 101-2000, 4.6.12.1 requires that "every...item of equipment / system required by this Code shall be continuously maintained in proper operating condition." These doors had an impediment to closing them so they would not limit the transfer of smoke should a fire occur. Seven (7) doors out of 20 plus tested sets of fire / smoke doors were so affected.

Findings are:

During the survey inspection on June 7, 2010 with Safety management Manger, observed that this requirement was not met as evidenced in the following locations:

1. At 3:11 p.m. on the first floor, observed NAMI closet rated door propped open.

2. At 4:04 p.m. on the first floor, observed Storage room, discovered two wooden wedges holding open a rated door.

3. At 4:07 p.m. on the first floor, observed in corridor held open with a friction type device at the floor level, this were not connected to a magnetic device or tied into the fire alarm system.

4. At 4:20 p.m. on the first floor, observed two leaf type doors in an eight foot corridor with one having a carriage type lock installed to prevent entry or access from one direction.

5. On June 8, 2010 at 9:32 a.m., therapist room observed the door to be blocked from opening 90 degrees.

6. On the second floor at 11:38 a.m., observed janitors closet door to be blocked from opening 90 degrees.

7. On the third floor at 11:56 a.m., observed network 'K' room with door blocked open with debris.

Based on observation and interview, the facility failed to comply with exit sign requirements. Per NFPA 1-97, 4-7 ... "Exits shall be marked by an approved sign readily visible from any direction of exit access." Failure to maintain these lighted directional signs could lead to confusion and possibly panic should an emergency evacuation (horizontal exiting) become necessary.

Findings are:

During the survey inspection on June 7, 2010 with Safety management Manger, observed that this requirement was not met as evidenced in the following locations. On the first floor at 4:46 p.m. in STAR corridor, observed exits sign facing the wrong direction (out).

Based on interviews about fire / emergency drills with facility staff, the facility did not provide effective evidence that fire drills are held under varying conditions (scenarios), at least quarterly on each shift for the laboratory. Therefore, the facility did not ensure that all laboratory staff were familiar with varying aspects of the emergency procedures. Per 19.7.1.2, "Employees of health care facilities shall be instructed in life safety procedures and devices." Staff needs to be prepared to execute their duties during all emergency situations / scenarios.

Findings:


Based on observations and record review, no documentation was recorded to prove that on the first quarter of 2010 for the third shift had participated in any fire drills. Documentation demonstrated that four months had lapsed from December 2009 until April 2010 for a fire drill to be performed.

Based on observations and interviews with staff members, determined that the facility did not maintain protection per NFPA 101-2000, 4.6.12.1 requires that 'every...item of equipment / system required by this Code shall be continuously maintained in proper operating condition'.

Findings:

During the survey inspection on June 7, 2010 with Safety management Manger, observed that this requirement was not met as evidenced in the following locations. On the first floor at 3:38 p.m. in medical records, observed smoke detector incorrectly installed incorrectly on the ceiling tile. It was installed less than 4 inches from the wall in an area that would cause air turbulence in case of smoke and affect its operation per manufacturer installation requirements.

Based on observations, record review and interviews, the facility did not maintain sprinkler piping and fittings per NFPA 101-2000, 9.7.5 requires that "all automatic sprinkler systems required by this Code shall be continuously maintained in reliable operating condition at all times. . . ." and per NFPA 25, 2-4.1.8. Some areas had fire sprinkler heads with missing / loose escutcheon rings. Four (4) of eight smoke compartments sampled were so affected.

Findings:

During the survey inspection on June 7, 2010 with Safety management Manger, observed that this requirement was not MET as evidenced in the following locations:

On the first floor
1. at 3:17 p.m. in NAMI closet, observed broken ceiling tiles that would affect fire sprinkler performance.

2. at 3:33 p.m. in medical records, observed Fire sprinkler with damaged escutcheon plate, also 6 of 10 fire sprinklers were covered in dust and debris which could affect the effectiveness of activation of the sprinklers in case of a fire.

3. at 3: 47 p.m. in main conference storage, observed missing ceiling tiles that would affect fire sprinkler activation in case of a fire.

4. at 3: 48 p.m. in Princeton conference room storage, observed missing ceiling tiles that would affect fire sprinkler activation in case of a fire, also fire sprinkler blocked by light fixture, needs extended head.

5. at 4:02 p.m. in environmental room, observed missing ceiling tiles that would affect fire sprinkler activation in case of a fire.

6. at 4:40 p.m. in STAR corridor, observed fire sprinkler missing escutcheon plate.

7. at 5:11 p.m. in file storage room, observed 18 inch rule not being adhered to.

On June 8, 2010
8. at 9:32 a.m. in COP therapist room, observed in adequate protection due to columns 16 inches by 16 inches blocking spray patter from fire sprinkler (class 'A' flammables).

9. at 9:43 a.m. on network closet, observed missing ceiling tiles that would affect fire sprinkler activation in case of a fire.

10. at 9:56 a.m. in CRC hall mop room, observed fire sprinkler escutcheon plate broken and ceiling tiles with large gaps.

11. at 10 a.m. in CRC client lounge, observed fire sprinkler with missing escutcheon plate.

12. at 10:18 a.m. in CRC electrical room, observed ceiling tiles with large open gaps affecting fire sprinkler performance.

13. at 10:41 a.m. in Pharmacy, observed solid shelving 9 inches from the ceiling affecting fire sprinkler performance.

Second Floor
14. at 11:42 a.m. in STARS area observed open ceiling tiles affecting fire sprinkler performance.

Third Floor
15. at 11:56 a.m. in network 'K' room observed open ceiling tiles affecting fire sprinkler performance.

16. at 12:18 p.m. in 3 clothing storage rooms observed open ceiling tiles affecting fire sprinkler performance.

Fourth Floor
17. at 12:25 p.m. in dumb waiter room observed open ceiling tiles affecting fire sprinkler performance.

Based on observation, the facility failed to maintain fire extinguishers as required. The deficient practice affected three out of 8 smoke compartments.

Findings:

During the survey inspection on June 7, 2010 with Safety management Manger, observed that this requirement was not met as evidenced in the following locations:

On the first floor
1. at 3:44 p.m. in case management office, observed missing fire extinguisher in hose cabinet number 34.

On June 8, 2010
2. at 9:48 a.m. in CMC (children's medical clinic), observed fire extinguisher in need of recharge.

Third Floor
3. at 12:02 p.m. at 3 east stair well, observed missing fire extinguisher.

Based on observations, interviews and testing, the facility failed to maintain the ventilation system equipment in accordance with NFPA 90A and with NFPA 101-2000, 4.6.12.4, "every...item of equipment required by this Code shall be continuously maintained in proper operating condition." Little or no ceiling exhaust ventilation (exchange of air) when tested observed in three (3) of 8 sampled smoke zones were so affected.

Findings:

During the survey inspection on June 8, 2010 with Safety management Manger, observed that this requirement was not met as evidenced in the following locations:

1. at 9:53 a.m. in CRC hall mop closet, observed exhaust vent clogged.

Second Floor
2. at 11:42 a.m. in OB number 6, observed ceiling air condition vent was not secure in danger of falling.

Fourth Floor
3. at 12:34 p.m. in Kitchen (small room) exhaust not working (refrigerator and ice maker) in room.

Based on an observation and interviews, the facility failed to maintain construction, protection, and occupancy features necessary to minimize danger to life from smoke, fumes or panic should a fire or similar emergency occur. The facility failed to maintain existing fire protection and life safety features such as smoke compartments and smoke construction per NFPA 101-2000 , 4.6.12.1-.4 "Features required by the Code...shall be thereafter permanently maintained." Five (5) out of 15 sampled smoke compartments had unsealed penetrations.
Findings include:
During the survey inspection on June 7, 2010 with Safety management Manger, observed that this requirement was not met as evidenced in the following locations:

1. at 3:18 p.m. corridors, observed several fire alarm devices had been removed from walls and ceilings leaving open gaps in rated walls. Devices had been removed due to recent approved changed in the fire alarm system. The openings in the rated walls and ceiling have created a hindrance to the effective protection of the rated fire walls and smoke compartments. Safety Manger explained they are diligently addressing the situation in repairing the open penetrations through the facility.

2. at 3:18 p.m. corridor rated fire doors, observed penetrations above the door not protected.

3. at 3:54 p.m. electrical room, observed penetrations in rated wall.

4. at 4:02 p.m. environmental room, observed penetrations on the smoke wall

5. at 4:43 p.m. in STAR corridor electrical room, observed pipe penetrations in rated wall

On June 8, 2010
6. at 9:43 a.m. in Network closet, observed a 2 inch hole in the 1 hr rated wall.

7. at 10:51 a.m. in purchasing storage, observed penetration in rated wall not protected.

Second Floor
8. at 11:43 a.m. in North electrical room, observed penetrations in rated wall and mixing of fire caulks.

Third Floor
9. at 11:56 a.m. in network room, observed penetrations in rated wall.

10. at 12:09 p.m. in electrical room, observed penetrations in rated wall.

Based on observations and interviews with facility staff, determined that the facility did not maintain the following per the Code (NFPA 101-2000) and NFPA 99. The facility failed to maintain fire protection and occupancy features necessary to minimize danger to life. This includes not ensuring that auxiliary areas, (i.e., boiler room, etc.), were free of hazardous conditions. Also, they failed to maintain the required occupancy features per NFPA 101-2000, 19.7.5 & 10.3.5, storage of a material of a "'highly flammable character shall not be used.".

Findings:

At 3:20 on June 7, 2010 with Safety management Manger, observed that the stored compressed oxygen and acetylene tanks were stored in unsafe conditions. They were within twelve inches from a critical reset button that controlled pumps to the building.

Based on an observation and interviews with facility staff, the facility did not maintain the following per the National Electric Code (NEC); Article 517 and NFPA 99. The facility failed to maintain fire protection and occupancy features necessary to minimize danger to life. Use of temporary wiring for a high amperage / motorized device did not demonstrate compliance with the code standard. Twenty (20) out of 60 plus electrical devices sampled did not operate as required or did not meet with hospital standards.

Findings:

During the survey inspection on June 7, 2010 with Safety management Manger, observed that this requirement was not met as evidenced in the following locations:

1. at 3:11 p.m. in safety management manager office, observed a multi tap adapter with refrigerator and microwave plugged into it, surpassing its rated capacity.

2. at 3:30 p.m. in CFO restroom, observed florescent lamp missing protective lens cover.

3. at 3:33 p.m. in medical records, observed 1) electrical extension cord pinched by base board supplying computers, extension cords are for 30 day temporary use and danger of electrical fire due to incorrect placement of cord. 2) Refrigerator plugged into surge protector surpassing its rated capacity.

4. at 3:48 p.m. in Princeton conference room, storage observed florescent fixture with no lamp cover.

5. at 3:54 p.m. in electrical room, observed 1) electrical panels (LNAB, LCAB, LCA) with open spaces and breakers not identified. 2) Florescent lamp with no protective lens cover.

6. at 4:02 p.m. in environmental service, observed florescent lamp missing protective lens cover.

7. at 4:07 p.m. in nurse station, observed electrical surge protector hanging from cord end.

8. at 4:10 p.m. in nurse station office, observed orange electrical extension cord used as permanent supply, extension cords are to be used for 30 day temporary use only.

9. at 5:13 p.m. in electrical room, observed 1) electrical panels (LCAC, LNAC, LCX) with open spaces. 2) Florescent lamp missing protective lens cover.

On June 8, 2010
10. at 9:04 a.m. in Residential clinical manager, office observed surge protector hanging from cord end.

11. at 10:04 a.m. in CRC business office, observed daisy chained surge protectors (plugged into one another).

12. at 10:18 a.m. in CRC copy room, observed refrigerator plugged into surge protector, surpassing rated capacity of device.

13. at 10:36 a.m. in schedule room, observed power tap in use

14. at 10:47 in pharmacy break room, observed refrigerator plugged into surge protector, surpassing its rated capacity.

15. at 10:51 in pharmacy storage, observed over 20 florescent fixtures with no protective lens covers.

Second Floor
16. at 11:24 a.m. in Pharmacy, observed refrigerator plugged into surge protector, surpassing rated its rated capacity.

Third Floor
17. at 11:53 a.m. in Lounge, observed orange extension cord in use as permanent supply, only to be used as temporary 30 day use.

18. at 11:54 a.m. in payroll, observed extension cord used as permanent power supply, only to be used as temporary 30 day use.

Fifth Floor Penthouse
19. at 12:50 p.m., electrical panels (LPN) no panel schedule and open electrical openings in junction box.