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Based on observations, on June 13, 2017 at approximately 9:00 AM onward, the following deficiencies were noted:

1. Floor/ceiling assembly improperly firestopped at pneumatic tube system penetration - located on fourth floor beside elevator lobby.

2. PVC conduit improperly firsetopped at fourth floor mechanical room MR400 - staff could not provide installation instructions for firestop assembly provided at penetration.

3. Steel roof beam is not equipped with fireproofing above elevator equipment in penthouse near stair #3 - Penthouse enclosure rating shall be maintained equivalent to rating of elevator shaft.

4. There is an unsealed penetration in the floor/ceiling assembly in ice machine room.(kitchen area)

NFPA 101 2012 ed, Sect 19.1.6.1, 8.3.5

This deficiency effected one of 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 June 13, 2017 at approximately 9:00 AM onward, the following deficiencies were noted:

1. Means of egress is obstructed by wall mounted clerical pad - located beside room 336. Device is not self-closing when opened and released.

2. There is no guardrail at exit discharge adjacent to loading dock - dock is greater than thirty inches above grade.

3. Horizontal door between serving area and dining room is locked against egress from inside serving area.

4. Doors between dining room and corridor do not swing in the direction of egress - room is sized to seat 50 or more occupants.

5. Enclosed courtyard is not equipped with remote second exit discharge - discharge to publicway is not a smooth transition at intersection of curb and fence gate. Located at right of loading dock.

NFPA 101, 19.2.1, 7.1.10.1

This deficiency effected one of 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 June 13, 2017 at approximately 9:00 AM onward, the following deficiencies were noted:

Electromagnetic locks on exit discharge doors are incomplete - system is not equipped with delayed egress or on/off switches at each door with master on/off switch at supervised station. Locks are located on door to stair #4, beside room 225; and other exit doors on the same floor.

Note: Electromagnetic locks, as installed, did release with loss of power and activation of fire alarm system.

NFPA 101, 7.2.1.6.1, 19.2.2.2.6

This deficiency effected one of 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 June 13, 2017 at approximately 9:00 AM onward, the following deficiencies were noted:

There are holes in exit passageway enclosure - located in PACS Room in Radiology Suite.

NFPA 101 2012 ed, Sect 19.2.2.3, 19.2.2.4, 7.2

This deficiency effected one of 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 June 13, 2017 at approximately 9:00 AM onward, the following deficiencies were noted:

There is no exit sign at cross corridor smoke barrier doors - located near volunteer work room.

NFPA 101, Sects 19.2.10.1, 7.10

This deficiency effected one of 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 June 13, 2017 at approximately 9:00 AM onward, the following deficiencies were noted:

1. There is a wedge under door to respiratory therapy storage room.

2. Dumbwaiter doors are observed in the open position - room enclosure is incomplete and area is used for storage of combustibles.(Dispatch Room)

3. General storeroom doors are not self closing - doors are equipped with hold-open feature not connected to release with activation of fire alarm system.

4. There is no self-closing device on door to environmental services storage - located in basement level.

NFPA 101, Sects 19.3.2.1, 8.7.1

This deficiency effected one of 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 June 13, 2017 at approximately 9:00 AM onward, the following deficiencies were noted:

Note: This facility utilizes special locking arrangements 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. There is no sprinkler in electrical room - located in 2 East electrical room.

2. There is no sprinkler in CT IV station - located in Radiology Unit.

3. There are no sprinklers for ER exit discharge enclosure - bound by three walls and enclosing ramp.

NFPA 101, 2012 Ed, Sects 19.5.3, 7.2.1.6, 9.7 , NFPA 13, 2010 Ed.

This deficiency effected one of 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 June 13, 2017 at approximately 9:00 AM onward, the following deficiencies were noted:

1. There is no positive latching hardware on doors to dining room -these dining room doors provide required separation of dish conveyor opening at kitchen/dinningroom from corridor.

NFPA 101, 2012 ed Sect 19.3.6.3.5

This deficiency effected one of 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 June 13, 2017 at approximately 9:00 AM onward, the following deficiencies were noted:

There are holes in the rated smoke barrier that are not sealed - located above ceiling near room 244.

NFPA 101, 19.3.7.3, 8.6.7.(1)

This deficiency effected one of 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 June 13, 2017 at approximately 9:00 AM onward, the following deficiencies were noted:

1. There is no identification of circuit breaker and panelboard serving fire alarm panel in PACS Room fire alarm panel - located in Radiology Suite.

2. Fire alarm panel is wired to Critical Branch of Essential Electrical System - located in PACS Room.

3. Receptacle is wired improperly in clean utility room - located in birthing center. Receptacle wires are not enclosed in conduit or other protective jacket in louvered box.

4. There is no ground fault interrupter protection for receptacles beside sinks in kitchen serving area.

NFPA 101, Sections 19.5.1.1, 9.1.2, NFPA 70, 2011 ed.

This deficiency potentially affects all 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 June 13, 2017 at approximately 9:00 AM onward, the following deficiencies were noted:

There is no service access opening for duct smoke detector - air handling unit located in MR400.

NFPA 101, 19.5.2.1, 9.2, NFPA 90A, 2012 ed

This deficiency effected one of 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 June 14, 2017 at approximately 9:00 AM onward, the following deficiencies were noted:

There is no air handler manual emergency stop switch, located at or near a supervised station, in pain management center.

NFPA 101 Sect 19.5.2.1, 9.2; NFPA 90A 2012 ed

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 June 13, 2017 at approximately 9:00 AM onward, the following deficiencies were noted:

Oxygen cylinders are stored less than five feet from combustibles in clean utility room - located on fourth floor.

NFPA 99 2012 ed, 11.6.2

This deficiency effected one of 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 June 13, 2017 at approximately 9:00 AM onward, the following deficiencies were noted:

1. There is no remote manual stop switch for all emergency generators. NFPA 110, 2010 ed, Sect 5.6.5.6

2. Generator annunciator panel did not read emergency power system supplying load with loss of normal power to automatic transfer switch serving Life Safety Branch - Generators 1, 2, and 3.NFPA 110, Sect 5.6.6

3. There is no visual indicator for battery charger failure on annunciator panel serving generators 1, 2, and 3., NFPA 110, Sect 5.6.4.6

4. There are no specific gravity readings for generator battery electrolyte not Battery Conductance test documentation - documentation shall occur weekly in accordance with NFPA 110, 2010 ed, Sect 8.3.7.1.

NFPA 99, NFPA 110, Sect 8.3

This deficiency effected one of two smoke compartments.

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