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Based on observation, interview, and documentation review the facility failed to ensure the building separations, vertical openings, exit signage, fire rated smoke walls, hazardous area protection, exit access corridors, exit corridor width, delay egress doors, fire drills, sprinklers maintained, and linen/trash chute rooms complied with NFPA 101. This has the potential to affect all patients receiving services from the facility. (A710) The cumulative effects of these systemic practices resulted in the facility's inability to ensure the safety of the patients. The facility's census was 437.

Based on observation, interview, and documentation review, the facility failed to meet the requirements for life safety, specifically, the applicable provisions of the 2012 edition of the Life Safety Code of the National Fire Protection Association. This had the potential to affect all patients receiving services from the facility. The facility census was 437.

Findings include:

1. Please see K225 for findings related to the facility failing to ensure exit vestibule was protected and separate from vertical mechanical shafts and stairwells were free of penetrations.

2. Please see K311 for findings related to the facility failing to endure vertical chases were free of penetrations.