HospitalInspections.org

Based upon observations and staff interviews conducted from 4/14-4/17/2015, it was determined that the facility failed to properly maintain the fire rated ceiling by having penetrations in the ceiling and by having missing ceiling tiles.

The Findings Include:

It was observed on 4/15/2015 at approximately 10:07 am that there were penetrations from wires in the security office ceiling.

It was observed in the security office by the security camera wiring that there was a 2 ft by 4 ft hole in the ceiling with no ceiling tiles.

An interview was conducted at the time of the observations with the Maintenance Representative and he stated that the wires should not be penetrating the ceiling and that there should be ceiling tiles in the area by the security camera wiring.

It was observed on 4/15/2015 at approximately 11:32 am that there was no ceiling in the Men's locker room by the communication room.

An interview was conducted with the Maintenance Representative and he stated that there should be a ceiling in the shower room and that he is going to have the Maintenance staff go around and check all areas for missing ceiling tiles and penetration's in the ceilings.

It was observed on 4/16/2015 at approximately 8:50 am that there were wires for the Omni-cell penetrating the ceiling in the Dialysis suite medication room.

It was observed on 4/16/2015 at approximately 11:23 am that there was a ceiling penetration approximately 3 inches by 3 inches in room 2170.

It was observed on 4/17/2015 at approximately 9:07 am that there were penetrations in the ceiling and there were 2 ceiling tiles displaced by wires not allowing them to sit properly and causing an opening.

An interview was conducted with the Maintenance Representative at the time of the observation and he stated that he would have the wires properly routed so that penetrations would be alleviated and the ceiling tiles would sit properly in the ceiling.

Based upon observations and staff interviews conducted from 4/14-4/17/2015, it was determined that the facility failed to assure that nothing was stored in the smokeproof towers by having things stored on the 1st floor of the towers under the stairways.
The Findings Include:
It was observed on 4/15/2015 at approximately 11:00 am that there were items stored under the staircase in the 1C46 smokeproof tower. Under the staircase was a wooden chair, a mop, plastic bags, a janitorial cart with supplies and a broom.
An interview was conducted at the time of the observation with the Maintenance Representative and he stated that these items should not be stored here and that they would be moved as soon as possible.

It was observed on 4/15/2015 at approximately 3:38 pm that the following items were stored under the staircase in smokeproof tower E-1:
-six 15 foot wooden beams
-2 wooden beds and mattresses from the behavioral unit (as stated by the Maintenance Representative)
-4 wooden bedside rolling tables
-1 cart with linens on it
-five 4x8 sheets of plywood
An interview was conducted with the Maintenance Representative at the time of the observation and he stated that these items should not have been stored in the smokeproof tower.

It was observed on 4/17/2015 at approximately 11:35 am that the following items were stored under the staircase in smokeproof tower F-1:
-Two 1ft by 1ft cardboard containers with Mazola oil in them
-2 plastic containers
-2 sheets
An interview was conducted with the Maintenance Representative at the time of the observation and he stated that these items should not have been stored in the smokeproof tower.
Items should not be stored in the smokeproof towers since if items go on fire they would impede the ability for people to exit the facility through them in an emergency.

Based upon observations and staff interviews conducted from 4/13-4/17/2015, it was determined that the facility failed to assure that exits were readily accessible at all times by not having a hard surfaced path out of one exit and by having lightning grounding cables going across an exit egress path.

The Findings Include:

It was observed on 4/16/2015 at approximately 11:46 am that the Roof Exit egress pathway by the dialysis unit had 2 lightning grounding cables going across the Exit egress pathway creating a potentially hazardous condition.

An interview was conducted with the Maintenance Representative at the time of the observation and he stated that the cables should not be in the exit egress pathway and that he would have them moved as soon as possible.

It was observed on 4/17/2015 at approximately 11:37 am that there was no hard surfaced path leading to a public way from Exit F-1.

An interview was conducted with the Maintenance Representative at the time of the observation and he stated that he would have a hard surfaced path installed as soon as possible.

Based upon observations and staff interviews conducted from 4/14-4/17/2105, it was determined that the facility failed to assure that there were sprinkler heads installed in all areas of the facility and by having rooms with obstructed sprinkler heads.
The Findings Include:
It was observed on 4/14/2015 at approximately 12:38 pm that there was a light obstructing the sprinkler head in the Pharmacy Flammable storage room. If the head activated the water flow would be obstructed by the light.
An interview was conducted at the time of the observation and the Pharmacy Director stated that the light was obstructing the sprinkler head and that he would notify Maintenance as soon as possible to move the light.
It was observed on 4/16/2015 at approximately 11:55 am that there was no sprinkler head in the Dialysis laboratory area.
An interview was conducted at the time of the observation with the Maintenance Representative at the time of the observation and he stated that the room should have been sprinkled.
It was observed on 4/16/2015 at approximately 12:05 pm that there was no sprinkler head in the Dialysis locker room bathroom area.
An interview was conducted at the time of the observation with the Maintenance Representative at the time of the observation and he stated that the room should have been sprinkled.
It was observed on 4/16/2015 at approximately 12:09 pm that there was no sprinkler head in the Dialysis Oxygen room.
An interview was conducted with the Maintenance Representative at the time of the observation and he stated that the room should have been sprinkled.
It was observed at approximately 2:53 pm in the nuclear medicine work station that there was no sprinkler head.
An interview was conducted with the Maintenance Representative at the time of the observation and he stated that the area should have been sprinkled.
It was observed on 4/16/2015 at approximately 3:22 pm that there was no sprinkler head in room 4052 storage area.
An interview was conducted with the Maintenance Representative at the time of the observation and he stated that the room should have been sprinkled.
It was observed on 4/17/2015 at approximately 9:37 am that there was no sprinkler head in the room 3015 closet.
An interview was conducted with the Maintenance Representative at the time of the observation and he stated that the room should have been sprinkled.
It was observed on 4/17/2015 at approximately 9:40 am that there was no sprinkler head in the Pediatric storage room next to room 3180.
An interview was conducted with the Maintenance Representative at the time of the observation and he stated that the room should have been sprinkled.

Based upon observations and staff interviews conducted from 4/13-4/17/2015, it was determined that the facility failed to continuously maintain the sprinkler system in reliable operating condition by having corroded sprinkler heads, sprinkler heads with substances on them, dusty sprinkler heads and obstructed sprinkler heads.

The Findings Include:

It was observed on 4/15/2015 at approximately 9:59 am that the chemical storage area by the maintenance area had 2 corroded sprinkler heads.

An interview was conducted with the Maintenance Representative at the time of the observation and he stated that the heads should not be in that condition and that he would have them replaced as soon as possible.

It was observed on 4/15/2015 at approximately 10:03 am that room 1091 had a sprinkler head with paint on it.

An interview was conducted with the Maintenance Representative at the time of the observation and he stated that the head should not be in that condition and that he would have it replaced as soon as possible.

It was observed on 4/15/2015 at approximately 10:07 am in the security office closet that a sprinkler head was obstructed by storage being to high.

An interview was conducted with the Maintenance Representative at the time of the observation and he stated that the head should not be obstructed and that he would make appropriate adjustment in the room as soon as possible.

It was observed on 4/15/2015 at approximately 10:20 am that there were 2 corroded heads in the Morgue.

An interview was conducted with the Maintenance Representative at the time of the observation and he stated that the heads should not be in that condition and that he would have them replaced as soon as possible. He further stated that the sprinkler company would check sprinkler heads throughout the facility to assure that they were in appropriate condition.

It was observed on 4/15/2015 at approximately 10:28 am that there were 28 corroded sprinkler heads in the Doctors parking area, there were also 5 sprinkler heads with fire proofing sprayed on them (as stated by the Maintenance Representative).

It was observed on 4/15/2015 at approximately 11:49 am that the laundry bathroom sprinkler head had an unknown substance on it and a sprinkler head right outside the bathroom was corroded.

It was observed on 4/15/2015 at approximately 11:55 am that rooms 1037 and 1038 had corroded sprinkler heads in them.

It was observed on 4/15/2015 at approximately 11:57 am that room 1033 had a corroded sprinkler head in it.

It was observed on 4/15/2015 at approximately 12:10 pm that the Kitchen had 12 corroded sprinkler heads.

It was observed on 4/15/2015 at approximately 12:15 pm that the Dining Room had 10 dusty sprinkler heads and 2 corroded sprinkler heads.

It was observed on 4/16/2015 at approximately 11:06 am that there were 5 dusty sprinkler heads in the old dental clinic which is now closed.

It was observed on 4/16/2015 at approximately 11:26 am that the Entrance Area for the Community Health Area had 4 corroded sprinkler heads.

It was observed on 4/16/2015 at approximately 11:28 am that the Vending area by the Emergency Room hallway had a corroded sprinkler head.

It was observed on 4/16/2015 at approximately 11:29 am that the Emergency Room Entrance had 4 corroded sprinkler heads.

It was observed on 4/16/2015 at approximately 11:33 am that the Emergency Room Fast Track room had a corroded sprinkler head.

It was observed on 4/16/2015 at approximately 11:45 am that room 2185 had storage that was too high and would impede the flow of the sprinkler head if it was activated.

It was observed on 4/16/2015 at approximately 11:56 am that a sprinkler head across from dialysis station #4 was dusty.

It was observed on 4/16/2015 at approximately 12:00 pm that the sprinkler head by dialysis station #15 was dusty and corroded.

It was observed on 4/16/2015 at approximately 12:03 pm that there was a dusty sprinkler head over the nursing station in the dialysis area.

It was observed on 4/16/2015 at approximately 12:07 pm that there was a dusty sprinkler head in the dialysis utility room.

It was observed on 4/16/2015 at approximately 2:43 pm that there were 2 sprinkler heads obstructed by storage that was too high and would impede the flow of the sprinkler heads if activated in the X-ray film room.

It was observed on 4/16/2015 at approximately 2:50 pm that there were 2 dusty sprinkler heads in room 2319.

It was observed on 4/16/2015 at approximately 3:16 pm that there was an unknown black substance on a sprinkler head in room 4133.

Based on observations and staff interviews conducted on 4/15/2015, it was determined that the facility failed to have the Emergency Oxygen (10 H tanks) supply properly secured to assure that the tanks could not fall or be knocked over.

The Findings Include:

It was observed on 4/15/2015 at approximately 12:23 pm that the facility had an Emergency Oxygen supply hooked into the facility which consisted of 10 H tanks. The H tanks were not secured in any type of fashion to assure that the H tanks were not able to fall or be knocked over, the tanks were free standing.

An interview was conducted with the Maintenance Representative at the time of the observation and he stated that the Oxygen tanks would be secured as soon as possible so they could not fall or be knocked over.

Based upon observations and staff interviews conducted on 4/15/2015, it was determined that the facility failed to properly utilize their flammable cabinets by having their doors obstructed and by leaving a door open and unlocked in the bottom cabinet in the laboratory, next to a potential fuel source.

The Findings Include:

It was observed on 4/15/2015 at approximately 11:19 am that there were 3 cabinets for flammable liquids stored on top of one another in the Media prep room in the laboratory. The middle cabinet had a sign on it that stated "stop do not block bottom cabinets." There was a pallet in front of the flammable containers blocking them from fully opening their doors. One door from the bottom flammable liquids cabinet was open and not secured. The items on the pallet were items to be shredded and had the potential of being a fuel source in the event that the flammable items went on fire since the door to the cabinet was open and not secured.

An interview was conducted with the Maintenance Director at the time of the observation and he stated that the materials should not have been stored so close to the flammable cabinet and that the cabinet door should have been secured.

Based upon observations and staff interviews conducted from 4/14-4/17/2015, it was determined that the facility failed to comply with NFPA 70 and National Electric Code 9.1.2 by having powerstrips daisy chained, plug adaptors and by utilizing extension cords.

The Findings Include:

It was observed on 4/15/2015 at approximately 9:44 am that there were powerstrips daisy chained in the Director of Facilities Management office.

An interview was conducted with the Maintenance Representative and he stated that he would have them removed as soon as possible and that they should not have been utilized in that way.

It was observed on 4/15/2015 at approximately 10:26 am that there was an extension cord in use in the Treatment planning room C-137.

An interview was conducted with the Maintenance Representative at the time of the observation and he stated that the extension cord should not have been in use and that it would be removed as soon as possible.

It was observed on 4/15/2015 at approximately 11:30 am that there was an extension cord in use in the communication room.

An interview was conducted with the Maintenance Representative at the time of the observation and he stated that the extension cord should not have been in use and that it would be removed as soon as possible.

It was observed on 4/15/2015 at approximately 11:39 am that there was an extension cord in use in the materials management room.

An interview was conducted with the Maintenance Representative at the time of the observation and he stated that the extension cord should not have been in use and that it would be removed as soon as possible.

It was observed on 4/15/2015 at approximately 11:53 am that there was an extension cord and 2 plug adaptors in use in the Director of Environmental Services office.

An interview was conducted with the Maintenance Representative at the time of the observation and he stated that the extension cord and plug adaptors should not have been in use and that it they would be removed as soon as possible.

It was observed on 4/15/2015 at approximately 3:12 pm that there was an extension cord in use in room 5080.

An interview was conducted with the Maintenance Representative at the time of the observation and he stated that the extension cord should not have been in use and that it would be removed as soon as possible and that he would check the entire facility for the use of plug adaptors, daisy chaining and extension cords.

It was observed on 4/15/2015 at approximately 3:43 pm that there were daisy chained powerstrips in room 2135.

It was observed on 4/15/2015 at approximately 3:43 pm that there were daisy chained powerstrips in room 2120.

It was observed on 4/15/2015 at approximately 3:59 pm that there was an extension cord in use in room 2067.

It was observed on 4/16/2015 at approximately 9:54 am that there was an extension cord in use in room 2107.

It was observed on 4/16/2015 at approximately 11:24 am that there was a 6 plug adaptor in use in room 2171.

It was observed on 4/16/2015 at approximately 11:25 am that there was an extension cord in use in room 2152.

It was observed on 4/16/2015 at approximately 11:43 am that there was a 4 plug adaptor in use in the Emergency Room medication room.

It was observed on 4/16/2015 at approximately 2:15 pm there were 3 powerstrips daisy chained in the Medical Records room.

It was observed on 4/16/2015 at approximately 2:22 pm there were 2 powerstrips daisy chained in the Business Office.

It was observed on 4/16/2015 at approximately 3:04 pm there were 2 powerstrips daisy chained in room 4187 at 2 different desks.

Based upon observations and staff interviews conducted from 4/13-4/17/2015, it was determined that the facility failed to properly install Alcohol Based Hand Rub (ABHR) dispensers by installing them over or adjacent to ignition sources.

The Findings Include:

It was observed on 4/15/2015 at approximately 9:45 am that there was an ABHR dispenser directly over an electrical outlet in the Director of Facilities management office.

An interview was conducted with the Maintenance Representative at the time of the observation and he stated that it should not be over the outlet and that he would move it as soon as possible.

It was observed on 4/16/2015 at approximately 12:09 pm that there was an ABHR dispenser adjacent to a light switch in the Rehabilitation waiting room.

An interview was conducted at the time of the observation with the Maintenance Representative and he stated that the ABHR dispenser should not be next to the light switch and that he would move it as soon as possible and that he was going to have the Maintenance staff check all of the ABHR dispensers all over the facility to assure that they were appropriately installed and not near ignition sources.

It was observed on 4/16/2015 at approximately 1:50 pm that there was an ABHR dispenser inches over a computer in exam room 3 C-234

It was observed on 4/16/2015 at approximately 2:51 pm that there was an ABHR dispenser adjacent to a light switch in room 2319.

It was observed on 4/16/2015 at approximately 2:54 pm that there was an ABHR dispenser adjacent to a light switch in room 2354.

It was observed on 4/16/2015 at approximately 2:55 pm that there was an ABHR dispenser adjacent to a light switch in room 2338.

It was observed on 4/16/2015 at approximately 3:20 pm that there was an ABHR dispenser adjacent to a light switch in room 4154.

Based upon observations and staff interviews conducted from 4/14-4/17/2015, it was determined that the facility failed to properly maintain the fire rated ceiling by having penetrations in the ceiling and by having missing ceiling tiles.

The Findings Include:

It was observed on 4/15/2015 at approximately 10:07 am that there were penetrations from wires in the security office ceiling.

It was observed in the security office by the security camera wiring that there was a 2 ft by 4 ft hole in the ceiling with no ceiling tiles.

An interview was conducted at the time of the observations with the Maintenance Representative and he stated that the wires should not be penetrating the ceiling and that there should be ceiling tiles in the area by the security camera wiring.

It was observed on 4/15/2015 at approximately 11:32 am that there was no ceiling in the Men's locker room by the communication room.

An interview was conducted with the Maintenance Representative and he stated that there should be a ceiling in the shower room and that he is going to have the Maintenance staff go around and check all areas for missing ceiling tiles and penetration's in the ceilings.

It was observed on 4/16/2015 at approximately 8:50 am that there were wires for the Omni-cell penetrating the ceiling in the Dialysis suite medication room.

It was observed on 4/16/2015 at approximately 11:23 am that there was a ceiling penetration approximately 3 inches by 3 inches in room 2170.

It was observed on 4/17/2015 at approximately 9:07 am that there were penetrations in the ceiling and there were 2 ceiling tiles displaced by wires not allowing them to sit properly and causing an opening.

An interview was conducted with the Maintenance Representative at the time of the observation and he stated that he would have the wires properly routed so that penetrations would be alleviated and the ceiling tiles would sit properly in the ceiling.

Based upon observations and staff interviews conducted from 4/14-4/17/2015, it was determined that the facility failed to assure that nothing was stored in the smokeproof towers by having things stored on the 1st floor of the towers under the stairways.
The Findings Include:
It was observed on 4/15/2015 at approximately 11:00 am that there were items stored under the staircase in the 1C46 smokeproof tower. Under the staircase was a wooden chair, a mop, plastic bags, a janitorial cart with supplies and a broom.
An interview was conducted at the time of the observation with the Maintenance Representative and he stated that these items should not be stored here and that they would be moved as soon as possible.

It was observed on 4/15/2015 at approximately 3:38 pm that the following items were stored under the staircase in smokeproof tower E-1:
-six 15 foot wooden beams
-2 wooden beds and mattresses from the behavioral unit (as stated by the Maintenance Representative)
-4 wooden bedside rolling tables
-1 cart with linens on it
-five 4x8 sheets of plywood
An interview was conducted with the Maintenance Representative at the time of the observation and he stated that these items should not have been stored in the smokeproof tower.

It was observed on 4/17/2015 at approximately 11:35 am that the following items were stored under the staircase in smokeproof tower F-1:
-Two 1ft by 1ft cardboard containers with Mazola oil in them
-2 plastic containers
-2 sheets
An interview was conducted with the Maintenance Representative at the time of the observation and he stated that these items should not have been stored in the smokeproof tower.
Items should not be stored in the smokeproof towers since if items go on fire they would impede the ability for people to exit the facility through them in an emergency.

Based upon observations and staff interviews conducted from 4/13-4/17/2015, it was determined that the facility failed to assure that exits were readily accessible at all times by not having a hard surfaced path out of one exit and by having lightning grounding cables going across an exit egress path.

The Findings Include:

It was observed on 4/16/2015 at approximately 11:46 am that the Roof Exit egress pathway by the dialysis unit had 2 lightning grounding cables going across the Exit egress pathway creating a potentially hazardous condition.

An interview was conducted with the Maintenance Representative at the time of the observation and he stated that the cables should not be in the exit egress pathway and that he would have them moved as soon as possible.

It was observed on 4/17/2015 at approximately 11:37 am that there was no hard surfaced path leading to a public way from Exit F-1.

An interview was conducted with the Maintenance Representative at the time of the observation and he stated that he would have a hard surfaced path installed as soon as possible.

Based upon observations and staff interviews conducted from 4/14-4/17/2105, it was determined that the facility failed to assure that there were sprinkler heads installed in all areas of the facility and by having rooms with obstructed sprinkler heads.
The Findings Include:
It was observed on 4/14/2015 at approximately 12:38 pm that there was a light obstructing the sprinkler head in the Pharmacy Flammable storage room. If the head activated the water flow would be obstructed by the light.
An interview was conducted at the time of the observation and the Pharmacy Director stated that the light was obstructing the sprinkler head and that he would notify Maintenance as soon as possible to move the light.
It was observed on 4/16/2015 at approximately 11:55 am that there was no sprinkler head in the Dialysis laboratory area.
An interview was conducted at the time of the observation with the Maintenance Representative at the time of the observation and he stated that the room should have been sprinkled.
It was observed on 4/16/2015 at approximately 12:05 pm that there was no sprinkler head in the Dialysis locker room bathroom area.
An interview was conducted at the time of the observation with the Maintenance Representative at the time of the observation and he stated that the room should have been sprinkled.
It was observed on 4/16/2015 at approximately 12:09 pm that there was no sprinkler head in the Dialysis Oxygen room.
An interview was conducted with the Maintenance Representative at the time of the observation and he stated that the room should have been sprinkled.
It was observed at approximately 2:53 pm in the nuclear medicine work station that there was no sprinkler head.
An interview was conducted with the Maintenance Representative at the time of the observation and he stated that the area should have been sprinkled.
It was observed on 4/16/2015 at approximately 3:22 pm that there was no sprinkler head in room 4052 storage area.
An interview was conducted with the Maintenance Representative at the time of the observation and he stated that the room should have been sprinkled.
It was observed on 4/17/2015 at approximately 9:37 am that there was no sprinkler head in the room 3015 closet.
An interview was conducted with the Maintenance Representative at the time of the observation and he stated that the room should have been sprinkled.
It was observed on 4/17/2015 at approximately 9:40 am that there was no sprinkler head in the Pediatric storage room next to room 3180.
An interview was conducted with the Maintenance Representative at the time of the observation and he stated that the room should have been sprinkled.

Based upon observations and staff interviews conducted from 4/13-4/17/2015, it was determined that the facility failed to continuously maintain the sprinkler system in reliable operating condition by having corroded sprinkler heads, sprinkler heads with substances on them, dusty sprinkler heads and obstructed sprinkler heads.

The Findings Include:

It was observed on 4/15/2015 at approximately 9:59 am that the chemical storage area by the maintenance area had 2 corroded sprinkler heads.

An interview was conducted with the Maintenance Representative at the time of the observation and he stated that the heads should not be in that condition and that he would have them replaced as soon as possible.

It was observed on 4/15/2015 at approximately 10:03 am that room 1091 had a sprinkler head with paint on it.

An interview was conducted with the Maintenance Representative at the time of the observation and he stated that the head should not be in that condition and that he would have it replaced as soon as possible.

It was observed on 4/15/2015 at approximately 10:07 am in the security office closet that a sprinkler head was obstructed by storage being to high.

An interview was conducted with the Maintenance Representative at the time of the observation and he stated that the head should not be obstructed and that he would make appropriate adjustment in the room as soon as possible.

It was observed on 4/15/2015 at approximately 10:20 am that there were 2 corroded heads in the Morgue.

An interview was conducted with the Maintenance Representative at the time of the observation and he stated that the heads should not be in that condition and that he would have them replaced as soon as possible. He further stated that the sprinkler company would check sprinkler heads throughout the facility to assure that they were in appropriate condition.

It was observed on 4/15/2015 at approximately 10:28 am that there were 28 corroded sprinkler heads in the Doctors parking area, there were also 5 sprinkler heads with fire proofing sprayed on them (as stated by the Maintenance Representative).

It was observed on 4/15/2015 at approximately 11:49 am that the laundry bathroom sprinkler head had an unknown substance on it and a sprinkler head right outside the bathroom was corroded.

It was observed on 4/15/2015 at approximately 11:55 am that rooms 1037 and 1038 had corroded sprinkler heads in them.

It was observed on 4/15/2015 at approximately 11:57 am that room 1033 had a corroded sprinkler head in it.

It was observed on 4/15/2015 at approximately 12:10 pm that the Kitchen had 12 corroded sprinkler heads.

It was observed on 4/15/2015 at approximately 12:15 pm that the Dining Room had 10 dusty sprinkler heads and 2 corroded sprinkler heads.

It was observed on 4/16/2015 at approximately 11:06 am that there were 5 dusty sprinkler heads in the old dental clinic which is now closed.

It was observed on 4/16/2015 at approximately 11:26 am that the Entrance Area for the Community Health Area had 4 corroded sprinkler heads.

It was observed on 4/16/2015 at approximately 11:28 am that the Vending area by the Emergency Room hallway had a corroded sprinkler head.

It was observed on 4/16/2015 at approximately 11:29 am that the Emergency Room Entrance had 4 corroded sprinkler heads.

It was observed on 4/16/2015 at approximately 11:33 am that the Emergency Room Fast Track room had a corroded sprinkler head.

It was observed on 4/16/2015 at approximately 11:45 am that room 2185 had storage that was too high and would impede the flow of the sprinkler head if it was activated.

It was observed on 4/16/2015 at approximately 11:56 am that a sprinkler head across from dialysis station #4 was dusty.

It was observed on 4/16/2015 at approximately 12:00 pm that the sprinkler head by dialysis station #15 was dusty and corroded.

It was observed on 4/16/2015 at approximately 12:03 pm that there was a dusty sprinkler head over the nursing station in the dialysis area.

It was observed on 4/16/2015 at approximately 12:07 pm that there was a dusty sprinkler head in the dialysis utility room.

It was observed on 4/16/2015 at approximately 2:43 pm that there were 2 sprinkler heads obstructed by storage that was too high and would impede the flow of the sprinkler heads if activated in the X-ray film room.

It was observed on 4/16/2015 at approximately 2:50 pm that there were 2 dusty sprinkler heads in room 2319.

It was observed on 4/16/2015 at approximately 3:16 pm that there was an unknown black substance on a sprinkler head in room 4133.

Based on observations and staff interviews conducted on 4/15/2015, it was determined that the facility failed to have the Emergency Oxygen (10 H tanks) supply properly secured to assure that the tanks could not fall or be knocked over.

The Findings Include:

It was observed on 4/15/2015 at approximately 12:23 pm that the facility had an Emergency Oxygen supply hooked into the facility which consisted of 10 H tanks. The H tanks were not secured in any type of fashion to assure that the H tanks were not able to fall or be knocked over, the tanks were free standing.

An interview was conducted with the Maintenance Representative at the time of the observation and he stated that the Oxygen tanks would be secured as soon as possible so they could not fall or be knocked over.

Based upon observations and staff interviews conducted on 4/15/2015, it was determined that the facility failed to properly utilize their flammable cabinets by having their doors obstructed and by leaving a door open and unlocked in the bottom cabinet in the laboratory, next to a potential fuel source.

The Findings Include:

It was observed on 4/15/2015 at approximately 11:19 am that there were 3 cabinets for flammable liquids stored on top of one another in the Media prep room in the laboratory. The middle cabinet had a sign on it that stated "stop do not block bottom cabinets." There was a pallet in front of the flammable containers blocking them from fully opening their doors. One door from the bottom flammable liquids cabinet was open and not secured. The items on the pallet were items to be shredded and had the potential of being a fuel source in the event that the flammable items went on fire since the door to the cabinet was open and not secured.

An interview was conducted with the Maintenance Director at the time of the observation and he stated that the materials should not have been stored so close to the flammable cabinet and that the cabinet door should have been secured.

Based upon observations and staff interviews conducted from 4/14-4/17/2015, it was determined that the facility failed to comply with NFPA 70 and National Electric Code 9.1.2 by having powerstrips daisy chained, plug adaptors and by utilizing extension cords.

The Findings Include:

It was observed on 4/15/2015 at approximately 9:44 am that there were powerstrips daisy chained in the Director of Facilities Management office.

An interview was conducted with the Maintenance Representative and he stated that he would have them removed as soon as possible and that they should not have been utilized in that way.

It was observed on 4/15/2015 at approximately 10:26 am that there was an extension cord in use in the Treatment planning room C-137.

An interview was conducted with the Maintenance Representative at the time of the observation and he stated that the extension cord should not have been in use and that it would be removed as soon as possible.

It was observed on 4/15/2015 at approximately 11:30 am that there was an extension cord in use in the communication room.

An interview was conducted with the Maintenance Representative at the time of the observation and he stated that the extension cord should not have been in use and that it would be removed as soon as possible.

It was observed on 4/15/2015 at approximately 11:39 am that there was an extension cord in use in the materials management room.

An interview was conducted with the Maintenance Representative at the time of the observation and he stated that the extension cord should not have been in use and that it would be removed as soon as possible.

It was observed on 4/15/2015 at approximately 11:53 am that there was an extension cord and 2 plug adaptors in use in the Director of Environmental Services office.

An interview was conducted with the Maintenance Representative at the time of the observation and he stated that the extension cord and plug adaptors should not have been in use and that it they would be removed as soon as possible.

It was observed on 4/15/2015 at approximately 3:12 pm that there was an extension cord in use in room 5080.

An interview was conducted with the Maintenance Representative at the time of the observation and he stated that the extension cord should not have been in use and that it would be removed as soon as possible and that he would check the entire facility for the use of plug adaptors, daisy chaining and extension cords.

It was observed on 4/15/2015 at approximately 3:43 pm that there were daisy chained powerstrips in room 2135.

It was observed on 4/15/2015 at approximately 3:43 pm that there were daisy chained powerstrips in room 2120.

It was observed on 4/15/2015 at approximately 3:59 pm that there was an extension cord in use in room 2067.

It was observed on 4/16/2015 at approximately 9:54 am that there was an extension cord in use in room 2107.

It was observed on 4/16/2015 at approximately 11:24 am that there was a 6 plug adaptor in use in room 2171.

It was observed on 4/16/2015 at approximately 11:25 am that there was an extension cord in use in room 2152.

It was observed on 4/16/2015 at approximately 11:43 am that there was a 4 plug adaptor in use in the Emergency Room medication room.

It was observed on 4/16/2015 at approximately 2:15 pm there were 3 powerstrips daisy chained in the Medical Records room.

It was observed on 4/16/2015 at approximately 2:22 pm there were 2 powerstrips daisy chained in the Business Office.

It was observed on 4/16/2015 at approximately 3:04 pm there were 2 powerstrips daisy chained in room 4187 at 2 different desks.