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Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1.

Findings include:

D. (Modified 03/06/12) The 7th Floor is used for conference rooms; there are no patient uses on the 7th Floor. Two of two exit stairs from the 7th Floor discharge into two separate 6th Floor exit access corridors. The corridors are in separate fire compartments (with at least two hour separation). The exit travel continues in the 6rh Floor corridor to two separate complying exit stairs.

The 6th Floor corridors are not designed to comply as exit passageways and the two 7th Floor stairs below do not comply with 7.7.1 or 7.7.2.

1. Exit Stair 14 (Southwest Wing).

2. Exit Stair 13 (Southeast Wing).



E. Corrected 03/06/12

Based on observation, exits are obstructed and not ready for immediate use.

A. Corrected 03/06/12

B. Corrected 09/13/12.

C. Corrected 03/06/12

1st Floor-West Building

D. (Modified 09/13/12): The exit discharge path from 1st Floor Occupational Therapy and the exit discharge for Exit Stair #3 has an existing exterior concrete stoop. The discharge path includes a 9" step down from the stoop to a ramp. The riser for the step exceeds that permitted under 7.2.2.2.1 b). The step has no handrail. (7.2.2.4.2)

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E. Corrected 03/06/12
F. Corrected 03/06/12
G. Deleted 3/06/12 .
H. Corrected 09/13/12
I. Corrected 03/06/12
J. Corrected 03/06/12

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

This item will remain open until all deficiencies have been corrected.