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It was determined through observation during the survey that the facility failed to maintain the means of egress in accordance with the Life Safety Code. This was evidenced by:

The exterior door in the dining room, which is labeled as an exit, does not have a maintainable surface to the public right-of-way, as required by NFPA 101, section 7.7.1.

This deficiency has the potential to affect all dining room occupants, including staff, visitors, and patients.

The means of egress deficiency item was discussed during the survey and again during the exit conference.

It was determined by observation during the survey, that the facility failed to provide and maintain the automatic fire sprinkler system in accordance with NFPA 13 and NFPA 25, as required. This was evidenced by the following:

1) The hot water piping serving the 1st and 3rd floors was found to be hung from supports attached to a sprinkler system branch line in the main boiler room. In accordance with NFPA 25 (1998), section 2-2.2, sprinkler piping shall not be subjected to external loads.
Note: this item was corrected during the survey.

This deficiency has the potential to affect all occupants of the rooms served by the branch line, which would be limited to staff only in this support area.

2) The two sprinkler heads located above the reception area in case management were found to be approximately 5-feet, 7-inches from one another. In accordance with NFPA 13 (1999), section 5-6.3.4, pendant sprinklers shall not be located closer than 6-feet to eachother.

3) The required escutcheon for the pendant style sprinkler head located in the bathroom in storage room #431 was missing.
Note: this item was corrected during the survey.

Deficiencies 2 and 3 have the potential to affect all occupants of the rooms listed, which is limited to staff only in the storage room and staff, visitors, and possibly patients in the case management area.

The automatic fire sprinkler system deficiency items were discussed during the survey and again during the exit conference.

It was determined by observation during the course of the survey that the facility failed to provide gas shut off valves in accordance with NFPA 99, Health Care Facilities, 4-3.1.2.3(d). This was evidenced by the following:

The gas shut off valves for the ICU area zone location was located within the same compartment as the zone, rather than having a "wall intervening between the valve and outlet" as required by NFPA 99.

This deficiency has the potential to affect all ICU occupants, including staff, visitors, and patients.

The gas shut off valve deficiency item was discussed during the survey and again during the exit conference.

It was determined through observation during the course of the survey, that the facility failed to provide the required battery backed-up emergency lights at the transfer switches in accordance with the Life Safety Code. This was evidenced by:

The facility failed to provide the required battery backed-up lights at two of two transfer switches, as required.
Note: This item was corrected during the survey.

The emergency light deficiency item was discussed during the survey and again during the exit conference.

It was determined through observation and staff interview, that the facility failed to install and maintain the essential electrical system in accordance with the Life Safety Code and NFPA 99, Healthcare Facilities. This was evidenced by:

The circuit for the island in the laboratory, which provides power for blood work operations, was found to be located on the Life Safety Branch. Per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2, this circuit should have been located on the Critical Branch.
Note: this item was corrected during the survey.

The essential electrical system deficiency item was discussed during the survey and again during the exit conference.