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1. Portions of the building were found to have unprotected structural steel. The surveyor finds that portions of structural beams have missing fire proofing. Example locations include:

a) Fourth Floor - Outpatient: Toilet Room in NW Doctor's Office west corridor.

2. Certain areas have spray on fireproofing on the underside of the concrete pan for the waffle slab. During an interview held in the building on the morning of July 14, 2010, the provider ' s Supervisor of Construction was not able to identify the UL Designs used to obtain the necessary construction type throughout the building. Documentation for the construction assemblies to comply with 19.1.6.2 and NFPA 220 1999 was not available on site (No UL Design Numbers).

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

Findings include:

A. Corrected 06/1/11
B. Corrected 12/28/10.

C. Sixth Floor: The ventilation shaft that connects 4 stories or more by Stair #2 was observed to not carry 2 hour rated enclosure as required by 19.3.1.1.

D. Corrected 12/28/10.
E. Corrected 12/28/10.

Based on observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4.

Findings include:

A. Fire alarm pull stations were observed which are not located within 5'-0" of the exit door as required by NFPA 72 1999 2-8.2.2. Locations observed include:

1. Fire alarm pull stations were observed to be located between the elevator doors and not within 5'-0" of the exit stair door located within the elevator lobbies leading to the exit stair.

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.