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A. Vertical openings between floors are not protected in accordance with 19.3. Conditions observed include:

1. The 2-hour rated enclosure of the East shaft could not be confirmed. The walls enclosing the shaft were observed to have exposed studs at the interior at the Penthouse, 2nd, and Basement levels.

2. Floor penetrations at the Special Procedures room M-81 were not sealed to afford the required 2-hour rating. This room was vacated and the specialized equipment had been removed without provisions made to maintain the floor barrier.

3. The Cancer Care addition contains a 3-story atrium connecting Basement, Ground & First floors. The following conditions were observed:

a. The enclosing walls of the atrium at the Ground floor do not comply with Exception No. 2 of 8.2.5.6. The enclosing walls at the Ground floor level are indicated to be of 1-hour rated construction. However, sprinkler protection is not provided on both sides of the glass windows/door assemblies to comply. It was not confirmed that the windows at this level and those located at the other levels were of tempered, wired, or laminated glass as required.

b. The reference plans also indicate that the enclosing walls at the Basement level are of 2-hour rated construction. The atrium is considered a single 3-story space. It is not clear why the 2-hour designation is indicated when the upper levels are indicated as only 1-hour construction.

c. It was not confirmed at the time of the survey that the installed smoke control system was equipped with controls to automatically activate the system upon sprinkler activation or that manual controls exist that are readily accessible to the fire department to comply with 8.2.5.6 (6).

4. The "clean lift" machine room located at the Basement level was not provided with a self-closing door to maintain the rated enclosure of the shaft.

A. Designated 2-hour enclosed/separated Exit stairs are not enclosed/separated in accordance with 19.3.1.1, 8.2.3.1.1 and 8.2.5.4. Conditions observed include but may not be limited to the following:

1. It was not confirmed that the gypsum board wall separating the east stair from the Penthouse was of 2-hour rated construction based upon the wall thickness observed.

2. The door at the bottom of the stair enclosure which also serves the Ground floor Radiology/Nuclear Medicine Office area is not labeled to confirm the minimum 1 1/2 fire rating.

A. Exit components are not constructed in accordance with 19.2 and 7.2. Conditions observed include:

1. The ramp accessing the Radiology Office area is not provided with handrails to comply with 19.2.2.6.1 and 7.2.5.

2. The exterior exit stair and landing at the exit near the compactor room lacks guard/handrails to comply with 19.2.2.3 and 7.2.2.4.

3. The exterior door at the Loading Dock is marked with exit signage. The stair outside this door does not conform to applicable requirements of 19.2.2.3 and 7.2.2.3 to qualify as a means of egress stair.

A. Based on observation the facility failed to install and maintain automatic sprinkler protection in accordance with the requirements of NFPA 101, 2000 Edition, Sections 19.3.5; NFPA 13, 1999 Edition, as well as NFPA 25, 1998 Edition Section 2-2.1.1, 2-4.1.4 and 5-4.1.4.

Findings include:
1. Tower Building- "A"Wing - Penthouse (10th Level) by the Medical Air Compressor #1: An Upright sprinkler head was installed improperly. This sprinkler head will not function if improperly installed.

B. Based upon observation the surveyor finds that sprinkler heads are covered with dust and lint throughout the Tower Building. Typical locations observed include but are not limited to:

1. Tower Building - "B" Wing - 8th Floor: Sprinkler head in Room 8-11.

2. Tower Building - "B" Wing" 8th Floor: Nurse Lounge and Kitchen Room 8-10.
3. Tower Building - 8th Floor - Room 8-10A by the Central Nurse Station.

4. Tower Building - "B" Wing - 3rd Floor: Exit access corridor by the elevator.

5. Tower Building - "A" Wing - Third Floor Respiratory Lounge.

C. Sprinkler systems are not installed and maintained in accordance with NFPA 13. Locations include:

1. Tower Building - 6th Floor, Tel. Closet 604: This room did not appear to have adequate sprinkler coverage, due to the room layout and obstructions of telephone wiring cables.

2. Tower Building -5th Floor, Electrical Room 521.3 lack sprinkler protection.

3. Tower Building "A" Wing - Fifth Floor, Room 510 Toilet: Ceiling panel was missing compromising the sprinkler protection of this area.

4. Tower Building "B" Wing - Fifth Floor, Room 521.1: This sprinklered room has multiple ceiling tiles that were missing which compromises the sprinkler system activation.

5. Tower Building "A" Wing - Fourth Floor, Room 439, Room 443, Room 409.1: Missing ceiling tiles in these rooms compromises the sprinkler system activation.

6. Tower Building "D" Wing - Fourth Floor, Day Room 430: The added passage in the North end of this room did not have sprinkler protection to comply with NFPA 13.

7. Tower Building "A" Wing - Third Floor, Room 367 has a missing ceiling tile which compromises the sprinkler system activation..

8. Tower Building "B" Wing Fifth Floor, Fan Room, this is being used for construction staging, ceiling panels are missing which compromises sprinkler activation.

D. Sprinkler heads were observed installed with less than 18 inches from the top of obstructions as prohibited by NFPA 13, 1999 5-5.6.

1. Tower Building - "C" Wing - Pharmacy Suite: The rolling shelves system in this area has the top shelves within 12" of the sprinkler heads.

E. The surveyor observed a number of spaces that are not sprinklerered in an otherwise sprinklered smoke compartment to comply with NFPA 13. Locations observed include but are not limited to:

1. Tower Building, Eight Floor, LDR #1 Patient Closets (2) in this room are not sprinklered.


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F. During the building walk-through an area on the fourth floor in "B" wing was observed to have ceilings removed with sprinkler heads left in the pendant position leaving the head more than 12" from the ceiling deck above and not in accordance with 5-6.4.1.1.

Based on random observation during the survey walk-through, not all portions of the building heating, air conditioning and ventilating system are installed and maintained in accordance with NFPA 90A 1999.

Findings include;

A. Access panels in ductwork throughout the facility were observed without lettering at least 1/2" high identifying the fire safety device within in accordance with 2-3.4.2.

B. Ducts were observed penetrating the penthouse floor without fire dampers in accordance with 3-3.2.

C. Ducts were observed penetrating the penthouse floor without access panels for maintaining fire safety devices within in accordance with 2-3.4.1.

D. During staff interview with the Maintenance Supervisor during the walk-through it was discovered the facility did not have current ventilation drawings with fire and smoke dampers identified on them in accordance with 3-4.6.1.

Based on random observation during the survey walk-through, not all portions of the building trash and linen chute system are installed in accordance with NFPA 82 1999.

Findings include;

A. The trash chute door on the ninth floor was observed to not be self closing in accordance with 3-2.4.2.