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Based on observation and interview, the facility failed to maintain portable floor plans that outlined designated rated partitions, affecting the entire facility.

Findings include:

Document review on April 30, 2024, at 10:30 a.m., revealed the facility failed to provide a set of accurate, portable floor plans. The Division of Safety Inspection is requiring that all facilities under its jurisdiction provide a portable, accurate floor plan on-site, to be used during the Life Safety Code Survey.

The Life Safety Code Floor Plan shall include the following:
a. Smoke barrier walls (outside wall to outside wall);
b. Fire barrier walls (1-2 hour walls);
c. Horizontal exits;
d. Rated rooms (storage rooms, soiled utility rooms, designated medical gas rooms) will be clearly designated. It is the facility's responsibility to have all rated rooms indicated on its Life Safety Code Floor Plan;
e. Required exits should be clearly noted;
f. Shaft walls.

Interview with the maintenance supervisor on April 30, 2024, at 10:30 a.m., confirmed the facility's Life Safety Code Floor Plan was unavailable at the time of the survey.

Based on observation and interview, the facility failed to maintain six of over fifty exit signs.
Findings include:
1. Observation on April 30, 2024, at 1:35 p.m., revealed the third floor smoke barrier doors, located next to the elevator lobby, had a missing exit sign above the doors.
Interview with the maintenance supervisor on April 30, 2024, at 1:35 p.m., confirmed the deficiency.
2. Observation on May 1, 2024, between 10:38 a.m. and 12:09 p.m., revealed the following exit sign deficiencies:
A. (10:38 a.m.) Ground floor break room, laboratory door to corridor, had a missing exit sign;
B. (11:14 a.m.) Ground floor smoke barrier door in x-ray department had a missing exit sign above the door;
C. (11:16 a.m.) Ground floor directional exit sign was missing near the entrance to the emergency room;
D. (12:02 p.m.) Ground floor smoke barrier doors, labeled "To Education Center," had a missing exit sign above the door;
E. (12:09 p.m.) Ground floor corridor from elevator seven, lobby to the x-ray department, had a missing exit sign above the door.

Interview with the maintenance supervisor on May 1, 2024, at 12:09 a.m., confirmed the exit sign deficiencies.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system for two of two building components.

Findings include:

Observation on May 1, 2024, at 10:56 a.m., revealed the sprinkler flow alarm switch, located on the sprinkler main, was missing the electrical protection cover. The electrical cover is necessary for circuit protection, and left unprotected, could lead to system malfunctions.

Interview with the maintenance supervisor on May 1, 2024, at 10:56 a.m., confirmed the missing cover on the water flow alarm device.

Based on observation and interview, the facility failed to maintain information and warning signs for gas and vacuum piped systems in two of over fifty rooms.

Findings include:

Observation on May 1, 2024, between 10:34 a.m. and 10:53 a.m., revealed the following deficiencies;
A. (10:34 a.m.) Ground floor, above smoke door near the pharmacy, had an unlabeled gas/vacuum line at the wall penetration above the lay-in ceiling tiles.
B. (10:53 a.m.) Ground floor mechanical room, in the ceiling above the man door, had an unlabeled gas/vacuum line at the wall penetration.

Interview with the maintenance supervisor on May 1, 2024, at 10:53 a.m., confirmed the piped systems were not labeled at the time of the survey.

Based on observation and interview, the facility failed to maintain electrical receptacles in nine of over fifty rooms.

Findings include:

Observation on May 1, 2024, between 10:40 a.m. and 12:28 p.m., revealed the facility failed to ensure electrical ground fault circuit interrupter (GFCI) protection within six feet of sinks in the following locations:
A. (10:40 a.m.) Ground floor histology lab;
B. (10:41 a.m.) Ground floor glassware washroom;
C. (10:43 a.m.) Ground floor micro-bio room;
D. (11:06 a.m.) Ground floor mechanical room;
E. (11:27 a.m.) Ground floor monogram dressing room;
F. (11:41 a.m.) Ground floor emergency room, ice and water machine;
G. (12:17 p.m.) First floor sleep lab, bathroom;
H. (12:23 p.m.) First floor SPU ice machine, near recovery room;
I. (12:28 p.m.) First floor SPU, break room.

Interview with the maintenance supervisor on May 1, 2024, at 12:28 p.m., confirmed the electrical outlet deficiencies.

Based on observation and interview, the facility failed to maintain gas equipment storage requirements on one of three building levels.

Findings include:

Observation on May 1, 2024, at 11:37 a.m., revealed an unsecured oxygen tank in the emergency department corridor on the ground floor. The deficiency was corrected at the time of the survey.

An interview with the maintenance supervisor on May 1, 2024, at 11:37 a.m., confirmed the deficiency.