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Based on observation and interview, the facility failed to ensure the automatic sprinkler and standpipe systems are inspected, tested and maintained in accordance with NFPA 25, resulting in the potential for harm to all occupants in the event of fire. Findings Include:

On October 28, 2022 at approximately 12:05 PM, observation revealed a missing ceiling tile in the Human Resources storage/office closet. This could allow heat to pass through the ceiling into the space above, delaying activation of the sprinkler head. These findings were confirmed with the Director of Facilities Operations at the time of observation.

Based on interview, the facility failed to ensure elevators are inspected and tested, including firefighter's service, as required by 18.5.3, 9.4.2 and 9.4.3. This deficient practice could affect 50 occupants in the event of firefighters' operation of the elevators in an emergency. Findings include:

On October 28, 2022 at approximately 2:00 PM documents regarding required elevator testing were requested. However, the facility could not produce the required documentation to verify monthly testing of the facility's elevators firefighters' operational control function. This could potentially cause the facility to not identify and correct an elevator failure and/or the elevator may not function as designed when needed during an emergency operation. These findings were confirmed with the Director of Facilities Operations Staff M at the time of finding.

Based on observation and interview, the facility failed to ensure smoking regulations were adopted and met all provisions as required by 18.7.4. This deficient practice could result in the potential for harm to 10 occupants in the employee smoking area.

Findings Include:

On October 28, 2022 at approximately 11:15 AM, observation of an employee smoking area revlead it did not contain ashtrays of noncombustible material and safe design, nor did the permitted smoking area have metal containers with self-closing cover devices readily available. These findings were confirmed through interview with the Director of Facilities Operations Staff M at the time of observation.

Based on observation interview, the facility failed to ensure portable space heating devices were prohibited and/or met safety regulations, resutling in the potential for harm to 35 occupants.

Findings Include:

On October 28, 2022 at approximately 10:45 AM, observation revealed a space heater located in the Social Workers' office in the Pediatric 1 female wing. The space heater contained wire heating elements and could not be verified that it does not exceed 212 degrees. This could potentially lead to a space heater related fire. These findings were confirmed with the Director of Facilities Operations Staff M at the time of observation.

Based on observation and interview, the facility failed to ensure generators were maintained in accordance with signage regulations. This deficient practice could result in harm to 10 occupants in the event of a fire.

Findings Include:

On October 28, 2022 at approximately 2:30 PM, observation revealed the facility failed to label the above ground diesel fuel tank that serves the generator with a "NFPA 704" placard and "NO SMOKING, FLAMMABLE" signs located where it can be seen on approach and easily identified by emergency responders. This could potentially lead to responders being unaware of the large amount of combustible fuel in the area. These findings were confirmed with the Director of Facilities Operations Staff M at the time of observation.

Based on observation and interview, the facility failed to ensure power strips were used in a safe manner. This deficient practice could result in harm to 50 occupants in the event of an electrical fire.

Findings Include:

On October 28, 2022 at approximately 12:00 PM, observation revealed a power strip was plugged into another power strip in the Intake Office Space. This could potentially overload the electrical power strips with a large amount of electrical resistance leading to an electrical fire. These findings were confirmed with the Director of Facilities Operations Staff M at the time of observation.