HospitalInspections.org

Based on document review and interview, the facility failed to maintain general requirements of the Life Safety Code that are not addressed by specific K-tags, but are still deficient for two of two building components.

Findings include:

Document review on December 30, 2025, at 11:02 a.m., revealed the facility failed to obtain required approval from the Department of Health State Plan Review and a granted occupancy from the Life Safety Division for the replacement of four elevators, two in Penthouse #4 and two in Penhouse #5.

Interview with the facilities director on December 30, 2025, at 11:02 a.m., confirmed the facility could not provide Plan Review documents at the time of the survey.

Based on observation and interview, the facility failed to maintain doors with self-closing devices, affecting one of over five doors.

Findings include:

Observation on December 30, 2025, at 11:25 a.m., revealed the first floor corridor's self-closing door, located near the environmental suite, failed to close and properly latch in the frame.

Interview with the maintenance supervisor on December 30, 2025, at 11:25 a.m. confirmed the door failed to latch in the frame.

Based on observation and interview, the facility failed to meet fire alarm system maintenance and testing requirements for one of one fire alarm panel.

Findings include:

Observation on December 30, 2025, at 11:35 a.m., revealed the fire alarm panel had a trouble signal present at the time of the survey.

Interview with the maintenance supervisor on December 30, 2025, at 11:35 a.m., confirmed the trouble signal and explained that it was due to the abatement of the 3B north wing.

Based on observation and interview, the facility failed to maintain portable fire extinguishers for three of over twelve months.

Findings include:

Observation on December 30, 2025, between 10:02 a.m. and 11:25 a.m., revealed the following fire extinguisher deficiencies at the time of the survey:

A. (10:02 a.m.) Lab extinguisher 116 was missing monthly inspections for May, June, and July;
B. (11:20 a.m.) Nuclear medicine extinguisher 26 was missing May, June, and July monthly inspections;
C. (11:25 a.m.) ER, near room 3, was missing May, June, and July monthly inspections.

Interview with the maintenance supervisor on December 30, 2025, at 11:25 a.m. confirmed the monthly inspections were missing for the fire extinguishers.

Based on document review and interview, the facility failed to maintain fire drills for four of four quarters.

Findings include:

Document review on December 30, 2025, at 12:00 p.m., revealed the facility had signatures for specific departments that participated in a fire drill each quarter. The facility was unable to provide documentation for all staff participating in a fire drill each quarter for each shift.

Interview with the maintenance supervisor on December 30, 2025, at 12:00 pm. confirmed the documentation was unavailable at the time of the survey.

Based on document review and interview, the facility failed to maintain fire drills for four of four quarters.

Findings include:

Document review on December 30, 2025, at 12:00 p.m., revealed the facility had signatures for specific departments that participated in a fire drill each quarter. The facility was unable to provide documentation that all staff participated in a fire drill each quarter for each shift.

Interview with the maintenance supervisor on December 30, 2025, at 12:00 pm. confirmed the documentation was unavailable at the time of the survey.

Based on observation and interview, the facility failed to maintain combustible decorations for one of one building component.

Findings include:

Observation on December 23, 2025, at 12:12 p.m., revealed the main entrance lobby had a Christmas tree that had no documentation of fire, flame, or smoke-proofing at the time of the survey.

Interview with the maintenance supervisor on December 23, 2025, at 12:12 p.m., confirmed the combustible decoration deficiency.

Based on document review and interview, the facility failed to maintain one of one piped-in gas and vacuum system.

Findings include:

Document review on December 30, 2025, at 10:10 a.m., revealed the following boiler room deficiencies at the time of the survey:

A. (10:10 a.m.) No source valve;
B. (10:10 a.m.) Main line vacuum switch not present;
C. (10:10 a.m.) Main line vacuum gauge not present;
D. (10:10 a.m.) No lag alarm;
E. (10:10 a.m.) System not monitored at master alarm panel.

Interview with the maintenance supervisor on December 30, 2025, at 10:10 a.m. confirmed the corrective documentation was unavailable at the time of the survey.

Based on observation and interview, the facility failed to maintain and inspect electrical system requirements, per NFPA 70 and NFPA 99, for two of more than twenty receptacles.

Findings include:

Observation on December 23, 2025, at 11:52 a.m., revealed the first floor main laboratory circuits 4 and 6 and the P262 break room had non-protected GFCI receptacles located within six feet of water basins.

Interview with the maintenance supervisor on December 23, 2025, at 11:52 a.m., confirmed the electrical system deficiencies.

Based on document review and interview, the facility failed to maintain one of two monthly essential electric maintenance requirements.

Findings include:

Document review on December 30, 2025, at 10:00 a.m., revealed the facility failed to provide documentation for monthly conductance testing of the generators at the time of the survey.

Interview with the maintenance supervisor on December 30, 2025, at 10:00 a.m. confirmed the documentation was unavailable at the time of the survey.

Based on document review and interview, the facility failed to maintain one of two monthly essential electric maintenance requirements.

Findings include:

Document review on December 30, 2025, at 10:00 a.m., revealed the facility failed to provide documentation for the monthly conductance testing of the generators at the time of the survey.

Interview with the maintenance supervisor on December 30, 2025, at 10:00 a.m. confirmed the documentation was unavailable at the time of the survey.