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A) Interim Life Safety Measures: 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.

1) Corrected 10/27/11

2) Corrected 01/12/12

3) Interim Life Safety Measures were not implemented for the conditions cited under K160.

4) The surveyor found an Mechanical Penthouse with and air handling unit and an elevator machine room. The elevator shaft was vented into the Penthouse and the air intake access door for the air handling unit was left open. The filter bank side of the air handling unit was heavily clogged and the unit was pulling air from the penthouse and the elevator shaft. This condition does not comply with NFPA 90A and/or ANSI A17.3. A daily log will be required to document that the access door to the air handling unit is closed and kept closed.

A) Modified 3/31/11: Based upon random observation and document review that surveyors find that three elevators are not installed and/or tested in accordance with ANSI A17.3.

3) (Modified 01/12/12): Based upon direct observation the surveyor finds that Elevator 1, 2 and 3 lacks automatic recall to a designated alternate floor in accordance with ANSI A17.3. Activation of a 1st Floor Elevator Lobby smoke detect results in recall of the elevator to the 1st Floor with the doors opening to the floor of fire origin.

On 1/12/12, one of three elevators was disabled and there were elevator contractors onsite working on the elevator and the elevator machine room. The elevator door for one elevator was found open and disabled at the 1st Floor. The surveyor found no interim measures for this condition. When asked the elevator contractor indicated that the elevator would initiate automatic fire department recall from the Lobby smoke detector without resetting the elevator to its normal operating mode. The provider failed to demonstrate this from testing on 01/12/12. One of three elevators did not automatically recall upon activation of the fire alarm system. Interim Life Safety Measures were not found for this condition. see K130.

The provider failed to notify the Department in writing that the above item would not be completed by the date indicated in the last submitted PoC (correction date was to be 12/30/11).