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Based on observation, not all stairs are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because their egress from the building could be impeded if the stairs are not properly constructed and maintained.

Findings include:

On June 26, 2019, while accompanied by the DPO, the following deficiencies were observed at the "scissor" style Exit Stairs in the building:

A. 8:39 AM: The doors to both Second Floor Exit Stair landings were observed to not carry a minimum 1-1/2 hour fire rating required by 39.3.1.1, 8.6.5(1), and Table 8.3.4.2.

B. 8:41 AM: At the Second Floor landing for the East "scissor" style Exit Stair, a door to a normally unoccupied space (a Closet) was observed as prohibited by 39.3.1.1 and 7.1.3.2.1(9).

Based on observation, not all building stories are provided with at least two remote exits. This deficient practice could affect patients, staff, and visitors in the building because they could be prevented from exiting the building under emergency conditions if an insufficient number of exits is provided.

Findings include:

On June 26, 2019 at 8:36 AM, while accompanied by the DPO, observation determined that the doors to the Second Floor "scissor" style Exit Stairs are no remote from each other as required by 39.2.4.1(2) and 7.5.1.3.3.

Based on observation, not all enclosures for hazardous areas are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass from the hazardous areas to the remainder of the building if the hazardous areas are not protected as required.

Findings include:

On June 25, 2019 at 2:06 PM, while accompanied by the DPO, observation determined that the smoke-proof enclosure walls for the First Floor Dry Storage Room are not complete, as required by 19.3.2.1.2 and 8.4.2(1), because a transfer grille exists above the door to the room.