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Based on observations, on Wednesday 6/28/2017 at approximately 10::00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The two hour fire resistance rated wall-occupancy separation (from adjacent Business Occupancy) has holes and penetrations that were not sealed in order to maintain the required fire resistance rating of the wall.
2012 NFPA 101: 6.1.14.4.2, 19.1.3.3

This deficiency effected one smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, on Wednesday 6/28/2017 at approximately 10::00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. There was storage in the means of egress at exit door. The means of egress was not maintained clear of obstructions. The items partially obstructing the corridor had been in place longer than 30 mins. The obstructions did not completely prevent egress.
NFPA 101: 19.2.1, 7.1.10.1

This deficiency effected one smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, on Wednesday 6/28/2017 at approximately 10::00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Emergency lighting at the two exterior exit discharge exits (leading to the public way) was not provided .
2012 NFPA 101: 19.2.8, 7.8.1.1

This deficiency effected one smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, on Tuesday 6/27/2017 at approximately 10::00 AM onward, the following deficiencies were noted:The standard is non-compliant, specific findings include:

1. In roof penthouse #2 exit directional signage was not provided for in the area. Occupant load is < 30, but the path of egress is not obvious/apparent.
NFPA 101, Sects 19.2.10.1, 7.10.2.1

This deficiency effected one smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, on Wednesday 6/28/2017 at approximately 10::00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Additional exit signage is needed in the therapy room (>2500 sq feet) in order for the two exits form the area to be indicated.
2012 NFPA 101, 19.2.10.1, 7.10.2.1

This deficiency effected one smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, on Tuesday 6/27/2017 at approximately 10::00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

Note : Building is fully sprinklered (NFPA 13 system)

1. The corridor door to the laundry room in the basement did not close and latch when checked
2. The corridor door to the sterile processing and decontamination room (> 50 sq ft and storage of Combustibles) in the surgery area did not close and latch when checked. Malfunction of existing door hardware.
3. The cooridor door to clean supplies and soiled utility room in the PACU did not close and latch when checked.

2012 NFPA 101, Sects 19.3.2.1.3, 8.7.1.3

This deficiency effected three smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, on Tuesday 6/27/2017 at approximately 10::00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

Note: This facility utilizes special locking arrangements (Delayed egress) therefore requiring fully sprinklered/smoke detection thru-out per NFPA 101, 2012 Ed, Sect 7.2.1.6. (The auto Supervised Spinkler option has been installed to meet this requirement)

1. In the roof penthouse #2 area is protected by approved fire suppression (sprinkler) system, there are mixed sprinkler heads in the facility rated for Intermediate Temperature Classification, Glass Bulb Color of Green temperature rating of (200°F) and Ordinary Temperature Classification, Glass Bulb Color of Red temperature rating of (155°F) in the same space. Note: The space is classified as ordinary environment.

Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. Sprinkler heads in same space/compartment shall be of same type or compatible heads. Compatibility shall be verified by Sprinkler System Design engineer of record, NICET Level III,
2010 NFPA 13, Section, 8.3.2, 2012 NFPA 101 Sect 19.3.5.1, 9.7

This deficiency effected one smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, on Tuesday 6/27/2017 at approximately 10::00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The supervisory signal for the electronically supervised tamper alarm on the sprinkler control valve at the Fire Alarm Control Panel (FACP) could be silenced permanently when the valve was in the closed position in the sprinkler riser room. Supervisory signals shall not be silenced permanently except by reopening/restoration of the valve to the normal operating position.

2012 NFPA 101 Section 9.7.2.1 Where supervised automatic sprinkler systems are required by another section of this code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, AND a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Supervisory signals shall sound and shall be displayed at a location within the protected building that is constantly attended by qualified personnel.


NFPA 101 Section 19.3.5.3, 9.7.2.1, 7.2.1.6 (Facility utilizing 100% Sprinkler option to meet special locking arrangements))

This deficiency effected sprinkler control valves.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, on Tuesday 6/27/2017 at approximately 10::00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The sprinkler heads located in the Laundry room and the corridor outside the corridor were not maintained clean and in good condition. Sprinkler heads were covered in dust and lint at the time of the survey.The sprinkler heads were covered in dust and lint that would affect the sensitivity of the sprinkler heads.

2. The sprinkler head located in the walk-in refrigerator in the kitchen was not maintained in good condition. The sprinkler head was covered in foreign material/corresion and not maintained in good condition and will need to be replaced.

2012 NFPA 101: 19.3.5.1; 9.7.5 , 2011 NFPA 25.5.2.1.1.1, 25.5.2.1.1.2,

This deficiency effected one smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, on Tuesday 6/27/2017 at approximately 10::00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. A section of the smoke barrier located above the corridor doors in the reception area adjacent to radiology has holes and penetrations that are not sealed in order to maintain the required fire resistance rating of the wall.

2012 NFPA 101: 19.3.7.3; 8.5; 4.5.8

This deficiency effected two smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, on Tuesday 6/27/2017 at approximately 10::00 AM onward, the following deficiencies were noted:: The standard is non-compliant, specific findings include:

1. The two remote generator annunciator panels located at the nurse station did not provide a signal for battery charger AC failure when checked.

2012 NFPA 99: 6.4.1.1.16.2 (Table item O),

This deficiency effected emergency generators.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.