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Based on observation and interview, the facility failed to maintain evacuation diagrams in one of two components.
Findings include:
Observation on February 12, 2025, between 10:59 a.m. and 11:09 a.m., revealed the evacuation diagrams did not contain a notation showing the location of the viewer on the diagram.
Ref: NFPA 170 - 11.2.4 & 11.3.2
Interview with the maintenance supervisor on February 12, 2025, at 11:09 p.m., confirmed the above deficiency existed.

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

Findings include:

Observation on February 12, 2025, at 10:22 a.m., revealed in the basement morgue laboratory room had been converted into a storage room containing combustible materials. This room does not meet hazardous area requirements. The facility changed the use of the room without the approval of State Plan Review and a granted occupancy from the Division of Life Safety.

Interview with the maintenance supervisor on February 12, 2025, at 10:22 a.m., confirmed the room had changed use without submitted plans to designate the rooms as hazardous storage areas.

Based on observation and interview, was determined that the facility failed to maintain smoke barrier construction on one of four levels.

Findings include:

Observation on February 12, 2025, at 11:37 a.m., revealed the first floor loading dock area, near door 1500, had grid work that needed repaired, as well as four missing ceiling tiles, allowing the passage of smoke.

Interview with the maintenance supervisor on February 12, 2025, at 11:37 a.m., confirmed the above smoke barrier deficiencies.

Based on observation and interview, the facility failed to maintain, inspect, and test smoke barrier doors, in accordance with regulations, on one of four levels.

Findings include:

Observation on February 12, 2025, at 12:44 p.m., revealed the facility failed to maintain the 3B north wing smoke barrier door. The door had a gap of 3/8", exceeding the 1/8" maximum allowance.

Ref: NFPA 80 6.3.1.7

Interview with the maintenance supervisor on February 12, 2025, at 12:44 p.m., confirmed the above smoke barrier door deficiency.

Based on observation and interview, the facility failed to maintain electrical outlets, to comply with Life Safety Code requirements and electrical safety policies, for two of two hydrocollators.

Findings include:

Observation on February 12, 2025, at 1:00 p.m., revealed the first floor physical therapy room had two hydrocollators that were not plugged into a ground fault circuit interrupter (GFCI) outlet.

Interview with the facilities manager on February 12, 2025, at 1:00 p.m., confirmed the above hydrocollators did not have GFCI protection.


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

Findings include:

Observation on February 12, 2025, between 10:35 a.m. and 12:32 p.m., revealed the facility failed to ensure ground fault circuit interrupter (GFCI) protection in the following areas:
A. (10:35 a.m.) Basement maintenance shop, receptacle within six feet of the sink;
B. (11:45 a.m.) First floor, outside of the men's locker room, near OR suite, receptacle within six feet of the sink;
C. (12:15 p.m.) First floor main lab, near the eye wash station, receptacle;
D. (12:30 p.m.) Third floor C wing laundry, washing machine receptacle;
E. (12:32 p.m.) Third floor soiled utility room, receptacle within six feet of the sink.

Interview with the maintenance supervisor on February 12, 2025, at 12:32 p.m., confirmed the electrical outlet deficiencies.

Based on observation and interview, the facility failed to install and maintain the emergency generator, per NFPA 110-5.6.5.6, for two of two emergency generators.

Findings include:

Observation on February 12, 2025, at 1:15 p.m., revealed the east and west emergency generators lacked a remote emergency shut off button on the exterior of the generator building.

Interview with the facilities manager on February 12, 2025, at 1:15 p.m., confirmed the emergency generators lacked a remote emergency shut off button on the exterior of the generator building.

Based on observation and interview, the facility failed to maintain gas equipment storage requirements in one of two storage areas.

Findings include:

Observation on February 12, 2025, at 10:45 a.m., revealed the first-floor oxygen storage room, near the loading dock, had oxygen cylinders that were unsegregated and not labeled as full or empty.

Interview with the maintenance supervisor on February 12, 2025, at 10:45 a.m., confirmed the oxygen cylinder deficiencies existed.