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Based on random observation during the survey walk-through on the afternoon of September 26, 2011, vertical openings between floors are not protected to comply with 19.3.1.1. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, because the lack of protection can allow smoke and fire to migrate from one floor to another.

Findings include:

A. Deleted 03/20/13
B. Corrected 09/18/12
C. Corrected 09/18/12
D. Corrected 03/20/13E. Corrected 09/18/12
F. Corrected 09/18/12
G. Corrected 03/20/13
H. Corrected 09/18/12

I. The Frankel building contains multiple access doors along the corridor walls which access chases (where only piping or conduit is sealed at the floor levels) or shafts (where the ducts extend through the floors). A clear delineation between those functioning as shafts from those functioning as chases was not apparent. The original installed access doors contained "Fire Door" labels without an hourly rating identified. This item has been corrected with self closing, positive latching, fire rated access panels (03/20/13).

a. Modified 03/20/13: The provider lacks
detailed information and plans that identify:

Ducts that penetrate fire rated floor
assemblies

Vertical openings including duct shafts or
open pipe chased that run the more than one
floor

The fire ratings for any and all shafts, vertical
openings and/or chases, including those that
are enclose and not rated but which are
smoke tight enclosures

Information, by floor and by shaft where fire
dampers are installed or not installed.

J. Corrected 09/18/12

Based on random observation during the survey walk-through, not all stair shafts used as exits are constructed in accordance with 7.2. These deficiencies could affect all occupants of the building because their ability to exit the building and reach a public way could be compromised.

Findings include:

A. During document review and staff interview conducted in the Facilities Office at 11:15 AM on September 27, 2011, it was determined that several building stories do not comply with 7.7.2. because less than 50 per cent of the exit stairs serving those building stories discharge directly to the exterior of the building. During the interview listed above, the provider's Vice President for Facilities confirmed the following:
1. Corrected 07/13/2016
2. Corrected 07/13/2016
3. Modified 7/23/14)
The Sixth Floor of the Olin-Sang,
Frankel, and Kurtzon Buildings are
served by Exit Stairs 4, 5, 6, 7, 8, and 9.
Of these, only Exit Stair 9 and Stair 4
discharge to the exterior to the building
in accordance with 7.7.1.

Update: On 07/13/2016, during staff interview, it was indicated that the required two hour enclosure is not complete behind the fire alarm panels in the exit passageway serving Stair #5.

4. Deleted 03/20/13

B. Deleted 03/20/13

Based on random observation during the survey walk-through, not all stair shafts used as exits are constructed in accordance with 7.2. These deficiencies could affect all occupants of the building because their ability to exit the building and reach a public way could be compromised.

Findings include:

A. During document review and staff interview conducted in the Facilities Office at 11:15 AM on September 27, 2011, it was determined that several building stories do not comply with 7.7.2. because less than 50 per cent of the exit stairs serving those building stories discharge directly to the exterior of the building. During the interview listed above, the provider's Vice President for Facilities confirmed the following:
1. Deleted 03/20/13
2. Deleted 03/20/13.
3. (Modified 07/23/14)
The Sixth Floor of the Olin-Sang,
Frankel, and Kurtzon Buildings are
served by Exit Stairs 4, 5, 6, 7, 8, and 9.
Of these, Exit Stair 9 and Stair 4
discharges exterior to the building
in accordance with 7.7.1.

Although identified as such, On
01/22/14, the provider was not
able to demonstrate how Stair # 4
complies with 7.7.1.

Update: On 07/13/2016, during staff interview, it was indicated that the required two hour enclosure is not complete behind the fire alarm panels in the exit passageway serving Stair #5.

4. The Sub-Basement of the Olin-Sang Building is served by exit stairs 5 and 13. Of these, none discharge directly to the exterior of the building.

Update: On 07/13/2016, during staff interview, it was indicated that the required two hour enclosure is not complete behind the fire alarm panels in the exit passageway serving Stair #5.

B. Deleted 03/20/13

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect all occupants of the listed building stories of the Kurtzon Building because their ability to successfully exit the building under fire conditions could be compromised.

Findings include:

A. Dead-end corridors of excessive length (in fire compartments classified as existing health care occupancies) were observed as prohibited by 19.2.5.10. Locations observed include:

1. Eighth Floor East Corridor.

2. Corrected 09/18/12

3. Sixth Floor:
a. Corrected 06/23/14
b. East Corridor.
B. Dead-end corridors in excess of 50'-0" in length (in fire compartments classified as existing business occupancies) were observed as prohibited by 39.2.5.2. Locations observed include:

1. Fifth Floor, south leg of West Corridor.

2. Fourth Floor, south leg - West Corridor.

3. Third Floor, south leg of West Corridor.

C. Corrected 09/18/12

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

Findings include:

A. September 26, 2011, varying times throughout the afternoon, and September 27, 2011, varying times throughout the morning: The conditions listed below were observed at a centrally located shaft within the Kurtzon Building (example location: at the Ninth Floor immediately southeast of the intersection between the East-West Corridor and the South Corridor). The shaft connects at least the Eleventh through Fourth Floors. These deficiencies could affect any occupants of the Kurtzon Building because fire and smoke could pass between building stories. Conditions observed include:

1. No evidence of fire dampers, required by
8.2.3.2.4.1. and NFPA 90A 1999 3-3.4.4.
was found on any building story in which
ductwork was observed in the shaft.
2. No access panels for any fire dampers,
required by NFPA 90A 1999 2-3.4.1.,
were found on any building story in
which ductwork was observed in the
shaft.
3. The shaft, which connects at least 8
building stories, was observed to not
carry a minimum 2 hour fire rating as
required by NFPA 90A 1999 3-3.4.1.,
because multiple unsealed penetrations
and openings (see 8.2.2. and
8.2.3.2.4.2.) were observed in the
shaft on all building stories observed.

A) Corrected 01/22/14




13755


A. Corrected 09/18/12



14290


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:

B. 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.

.

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.

.

Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.


Findings include:

1. Emergency loads were not separated into life safety, critical and equipment branches which does not meet the requirements of NFPA-70, Section 517-31 thru 35.

2. Transfer switches served locations rather than specific branches of the emergency system which does not meet the requirements of NFPA-70, Section 517-30(b)(4).

Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.


Findings include:

1. Emergency panels throughout the building were serving both life safety and critical loads which does not meet the requirements of NFPA-70, Section 517-31 thru 35.

2. Transfer switches served locations rather than specific branches of the emergency system which does not meet the requirements of NFPA-70, Section 517-30(b)(4).

Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.


Findings include:

1. The critical rather than life safety panels on each floor were serving med gas alarms, exit signs, and emergency lighting which does not meet the requirements of NFPA-70, Section 517-31 thru 35.

2. Transfer switches served locations rather than specific branches of the emergency system which does not meet the requirements of NFPA-70, Section 517-30(b)(4).

Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.


Findings include:

1. The critical rather than life safety panels on each floor were serving med gas alarms, exit signs, and emergency lighting which does not meet the requirements of NFPA-70, Section 517-31 thru 35. Examples include panel 5CR1 and 4CR2 which were serving med gas alarms and corridor emergency lighting.

2. Transfer switches served locations rather than specific branches of the emergency system which does not meet the requirements of NFPA-70, Section 517-30(b)(4).