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

Findings include:

A. The following deficiencies were observed at a pipe shaft on the Third Floor, located directly across from Exit Stair E-A (at which pipes were observed to not be sealed against the passage of fire at the floor):

1. During an interview held at the site, the provider's Director of Plant Services could not confirm that the shaft, which consists of metal lath and plaster, carries a minimum 1 hour fire rating as required by 8.2.5.4.
2. Corrected 03/30/11.

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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.

Findings include:

A. The Elevator Penthouse above the Third Floor was observed to be served solely by an exit stair which discharges interior to the building (Exit Stair E-C), and is thus not complete to a public way as required by 7.7.1.

B. Corrected 03/30/11.

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Based on document review and staff interview, the facility's fire alarm system is not inspected, tested, and maintained in accordance with 9.6.

Findings include:

A. Through document review, it was determined that the facility does not test fire alarm system components on a periodic basis as required by NFPA 72 1999 7-3.2. During an interview held in his Office on the afternoon of November 9, 2010, the provider's Director of Plant Services confirmed that 25 per cent of all fire alarm initiation devices are tested by an outside vendor each quarter. Review of the 4 most recent vendor-provided quarterly reports indicated that in each case, several devices were listed as not having been tested. However, none of the reports reviewed showed that these devices had been tested under a subsequent test. Therefore, not all fire alarm initiation devices are tested at least annually as required.

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Based on random observation during the survey walk-through, not all linen or refuse chutes are constructed an maintained as fire resistive assemblies.

Findings include:

A. The following deficiencies were observed at the Basement Level Soiled Linen Chute Discharge Room:

1. Corrected 03/30/11.

2. The door to the room was observed to not carry a minimum 1-1/2 hour fire resistance rating required by 8.2.3.2.3.1(1) and NFPA 82 1999 3-2.6.1.

NEW 03/30/11: The door to the room was observed to have been changed; however, the new door was observed to not carry a minimum 1-1/2 hour fifre resistance rating.

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Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3.

Findings include:

A. Carts, furnishings, and equipment were observed in exit access corridors that obstruct egress as prohibited by 19.2.3.3. and 7.1.10.2.1. Locations and items observed include:

1. Third Floor Nurses' Station:

a. Corrected 03/30/11.

b. Two chairs.

2. Corrected 03/30/11.

3. Corrected 03/30/11.

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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.

B. Corrected 03/30/11.

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