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Based on observations and interviews the facility failed to ensure the ceiling tiles in all areas, of the first floor, do not have cracks, do not leak, the smoke compartment is free of debris, and the reference lab is free of exhaust fumes.
Finding Include:

On 4/28/2010 at 10:45 AM, observations of the first floor hallways, laboratory, pharmacy, and central supply revealed:
1. Numerous ceiling tiles with apparent water stains, water stained light covers noted in the laboratory area, ceiling tiles cut to short leaving cracks in the ceiling tiles, stained towels lying in the floor, in the corner of the Chemistry lab, near the floor drain.
2. A makeshift drainage system is noted in Central Chemistry lab. This system has three drainage tubes/pipes running from the ceiling area to the floor drain. Employee Identifier (EI) # 10) stated the drains were put in to stop leaks in the ceiling when it rains outside.
3. Two drainage tubes/pipes were observed protruding out of the ceiling. These two drains extend across the ceiling, to the wall, (approximately one to three feet from the wall), and run down the wall to the floor drain. A third drain is a rubber lawn hose that from the chemistry labs refrigerator storage unit, this hose extends down the wall outside and beside the refrigerator door, and into the floor drain. All three drains are inserted into a floor drain that is located inside the fire doors of the special chemistry lab.
4. EI# 5 removed ceiling tiles to allow the surveyor to observe the ceiling drains/hoses and drain pans. Two drain pans were observed in the ceiling smoke compartment of the special chemistry laboratory. One drain pan is in the ceiling smoke compartment inside the special chemistry lab.
5. A second drain pan was observed in the ceiling smoke compartment between the fire doors that separate the special chemistry lab from the first floor hallway. Drains/hoses connect to the side of these large metal drain pans. EI# 3 said the ceiling drain pans collect water, when or if the roof leaks, and collect air-conditioning condensation. Water collected in the pans runs down the drain tubes/hoses that are inserted into the floor sewage drain. The pans appear to be larger than two foot in size, rectangular or square in shape, with sides approximately 2 inches in height. (Note: Measuring of these drain pans was not done as this would require detaching and removing the drain system from the ceiling smoke compartment).
6. An air vent, located above a drain pan in the chemistry lab, has a brown/tan colored material or substance on the surface. EI# 5 said this substance is a water barrier.
7. The surveyor observed towels in a ceiling smoke compartment.

The hospital facilities management staff (Employee Identifier # 3 and # 5/ interviewed 4/29/10 at 4:30 and 6:00 PM) stated the leaking ceilings on the first floor are an ongoing problem, as the second floor roof garden is the primary source of the leaks. Facility management have addressed the ceiling leaks for years and currently check the areas on the first floor after each rain. Ceiling tiles are replaced as identified post a rain, drain pans are checked, and recently drains have been added and connected to the floor drains. According to these staff members ceiling drain pans were added to the smoke compartment years ago and recently more pans and a drain added to try and control the leaking ceiling but the problem continues.