HospitalInspections.org

Based on observations as referenced in the Life Safety report of survey completed February 16, 2018, the hospital failed to have an effective governing body ensuring a safe environment for patients.

The findings include:

The hospital failed to develop and maintain the facilities in a manner to ensure the safety of patients.

~ cross refer 482.41 Physical Environment - Tag A0700

Based on observations as referenced in the Life Safety report of survey completed February 16, 2018, the hospital failed to develop and maintain the facilities in a manner to ensure the safety of patients.

Findings included:

The hospital failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association.

~Cross-refer to 482.41(a)(1) Physical Environment Standard Tag A-0702.

~Cross-refer to 482.41(b) Physical Environment Standard Tag A-0709.

Based on observations as referenced in the Life Safety Report of Survey completed February 16, 2018 the hospital staff failed to assure the safety of patients, staff, and visitors by failing to ensure the essential electrical system was maintained to provide emergency power and lighting to critical and appropriate areas of the hospital during outages of normal power.

Findings included:


Building 0107: Main Hospital:

1. Conductance testing for 4 of 5 emergency generators was documented quarterly instead of monthly.

Reference 2012 NFPA 101 19.2.9, 2010 NFPA 110 8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted.

This deficiency affected all smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0918



Building 0207: Outpatient Surgery

1. The remote generator annunciator located at the nurse station did not provide a signal for loss of (Emergency Power Supply) EPS supplying load or a battery charger AC failure when checked.

Reference 2012 NFPA 99: 6.4.1.1.16.2 (Table item O),

This deficiency affected all smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0918

Based on observations as referenced in the Life Safety Report of Survey completed Fabruary 16, 2018, the hospital staff failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association ensuring that the life safety from fire requirements are met.

Findings included:


Building 0107: Main Hospital:

1. The chain link fence in bulk storage (part of pharmacy) had a padlock on the area.
2. The emergency release handle in the freezer in the kitchen was not able to be see in all levels of light.

Reference NFPA 101 19.2.1, 7.1.10.1 Means of egress is continuously maintained free of all obstructions to full use in case of emergency.

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

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0211

1. Exit egress signage was not displayed from Peds ED waiting room.
2. Exit egress signage was not displayed from first floor imaging services.
3. Exit egress signage was not displayed from corridor 1049. Sign to MOB says not an exit.
4. Exit egress signage was not displayed at the end of the sub-basement center core service tunnel.
5. Exit egress signage was not displayed from the fire pump in the sub-basement.

Reference 2012 NFPA 101 Section 19.2.10.1 Means of egress shall have signs in accordance with Section 7.10, unless otherwise permitted by 19.2.10.3 or 19.2.10.4.

This deficiency affected four smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0293

1. The closure had been removed from the rated door to the vertical opening between floors at the end of the sub-basement service tunnel exit. The door was rated one hr, but would not self close and latch as required.

Reference NFPA 19.3.1.1 through 19.3.1.6 Vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour with one hr rated doors with slef closing devices. .

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

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0311

The following doors to hazardous areas did not close and latch smoke tight when tested:
1. The oxygen storage room located on the back loading dock was not equipped with self-closing device.
2. The door separating the house keeping closet from the central sterile storage room located next to operating room
3. The doors to OR equipment room A & B.
4. The door to 5 south clean supply, number 5253.
5. The doors to the Pulper Room next to the kitchen did not close and latch. The inactive leaf of the two doors was not locked in place at the time of the survey.
6. The Refuse room door next to the kitchen did not close and latch when checked.
7. The inactive leaf to the corridor door to mechanical room in the basement B356 was not secured in place and when checked the doors did not close and latch tight in its frame.

Reference NFPA 101, 19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1.
19.3.2.1.2 Doors shall be self-closing or automatic-closing.

This deficiency affected hazardous area and adjacent areas.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0321

1. The smoke detector in the MOB corridor was located within 3' of a HVAC supply regisiter

Reference NFPA 101 19.3.4.1, 9.6, 9.6.1.8

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

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0341

1. There is not sprinkler coverage in the hydraulic elevator shafts.12 of 25 elevator shafts are identified by the hospital as hydraulic.

Reference 2012 NFPA 101 19.3.5.1, 9.7 19.5.3, 9.4, 2010 NFPA 13 8-15 Elevator Hoistways and Machine Rooms 8.15.5.1 Sidewall spray sprinklers shall be installed at the bottom of each elevator hoistway not more than 2 ft. (0.61 m) above the floor of the pit. 8.15.5.2 Automatic sprinklers in elevator machine rooms or at the tops of hoistway shall be of ordinary or intermediate temperature rating. 8.15.5.5 The sprinkler required at the top of the elevator hoistway by 8.15.5.4 shall not be required where the hoistway for passenger elevators is noncombustible or limited-combustible and the car enclosure materials meet the requirements of ASME A17.1, Safety Code for Elevators and Escalators. 8.15.5.6 Sprinklers shall be installed at the top and bottom of elevator hoistway where elevators utilize polyurethane-coated steel belts or other similar combustible belt material.

This deficiency affected 12 of 25 elevator shafts that were identified as hydraulic.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0351

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.

Reference 2012 NFPA 101 Section 19.3.5.1, 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.

This deficiency affected all smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0352

1. The sprinkler heads located in the special procedures area were not maintained clean and in good condition. Sprinkler heads were covered in dust and lint at the time of the survey.
2. The sprinkler heads located in the lab area were not maintained clean and in good condition. Sprinkler heads were covered in dust and lint at the time of the survey.
3. At the time of the survey, documentation for the (3) three year flow test.could not be provided for sprinkler system for terrace canopy riser.

Reference 2012 NFPA 101 19.3.5.1, 19.7.6; 9.7.5, 4.6.12.1, 2011 NFPA 25.5.4.1.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, or other features shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.

This deficiency affected all smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0353

1. The corridor doors to north tower, second floor, data room has a louver installed in the lower half of the door and would not resist the passage of smoke.

Reference 2012 NFPA 101: 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Reference 2012 NFPA 101 19.6.3.2 (2) The door shall be constructed to resist the passage of smoke, 4.6.12.4 CMS S&C 07-18.

This deficiency affected one smoke compartment.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0363

The following smoke barrier walls had unsealed penetrations and/or had improperly firestopped penetrations.
The smoke barrier has penetrations that were not sealed or sealed with an unapproved sealant and need to be repaired/ sealed to provide a UL approved fire stop application.
1. Inside room 3004 had sheet rock mud in the smoke barrier.
2. Third floor above the cross corridor doors to stairwell I had black caulk in the smoke barrier. This item was corrected.
3. Third floor HMI ortho area, in the ceiling above the right leaf as you leave the joint care coordinator's office, had unsealed penetrations.
4. ED above cross corridor doors to zone A had black caulk.
5. ED above cross corridor doors to zone C had unsealed penetrations.
6. ED above corridor 1100 near room 1197 had open conduit.
7. ED/PSY above cross corridor doors had an unprotected cable tray.
8. Above the door to room 1049 at MOB had an unsealed penetration.
9. Cath Lab by lab #4 had an unsealed penetration.
10. Cath Lab managers office had an unsealed penetration.
11. Radiation Recovery above the double doors at the nurses station had an unsealed penetration.
12. The data closet in bulk storage, equipment room, had an unsealed penetration.
13. Endo at room A had an unsealed penetration in the wall above the ceiling tile located above the counter along corridor wall..
14. Lab, right bathroom, beside the break room has a 4' x 4' piece of sheet rock missing from the smoke barrier.

Reference 2012 NFPA 101 Sections 19.3.7.3, 8.5, 8.5.6.2, 8.5.6.3, 8.5.6.5
Reference 2012 NFPA 101 Sections 19.1.1.1.3, 19.1.1.2, 4.1.1, 4.2.3, 4.5.8, 4.6.12.2, 4.6.12.4, 43.5.1.3
Reference 2012 NFPA 101 Sections 19.5.1, 9.1.2
Reference 2011 NFPA 70 Articles 300-21, 760-3(a), 820-26, 830-26
Reference 2012 NFPA 101: 19.3.7.3; 8.5; 4.5.8 Smoke barriers shall be constructed to a 1/2-hour fire resistance rating

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

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0372

1. The opening in the smoke barrier door noted as room 1748, staff break room was not fire rated nor wired glass. The plans showed this door as part of the one hour smoke barrier.

Reference 2012 NFPA 101 19.3.7.6, 19.3.7.6.2, 8.5 Openings in smoke barrier doors shall be fire-rated glazing or wired glass panels in steel frames

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

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0379

1. The electrical outlet at 5 south break room at sink, 5285 was not GFCI protected.
2. The GFCI's in bulk storage did not function properly.

Reference 2012 NFPA 19.5.1.1, 9.1.1, 9.1.2, NFPA 70, National Electric Code

This deficiency affected two smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death due to electrical shock.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0511

1. The HVAC duct work did not have an service opening that would allow for the testing, inspection, maintenance, installation or cleaning of the smoke detector in the penthouse.

Reference NFPA 101 19.5.2.1, 9.2 NFPA 90A: 4.3.5.1

This deficiency affected one smoke compartment.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0521

1. Based on observation on the sixth and seventh floor, the facility failed to limit trash/soiled linen collection receptacles in corridors to 32 gallons in capacity. Trash/Soiled linen containers were found >32 gal capacity.

Reference 2012 NFPA 101, 19.7.5.7.1 Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in capacity and shall meet all of the following requirements:
(1) The average density of container capacity in a room or space shall not exceed 0.5 gal/ft2 (20.4 L/m2).
(2) A capacity of 32 gal (121 L) shall not be exceeded within any 64 ft2 (6 m2) area.
(3)*Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended.
(4) Container size and density shall not be limited in hazardous areas.

This deficiency affected six smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0754

1. Oxygen storage was within five feet of combustibles, in Day of Surgery (DOS) oxygen storage room.
2. Oxygen storage was within five feet of combustibles, in suite CVSS oxygen storage room.

Reference 2012 NFPA 101 19.3.2.4, 99 11.3.2.3 Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following: (1) Minimum distance of 6.1 m (20 ft) (2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13.3 Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/2 hour.

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

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0923


Building 0207: Outpatient Surgery

1. The smoke detector near room 18 and soiled utility was located within 3' of a HVAC supply register.

Reference NFPA 101 21.3.4.1, 9.6, 9.6.1.8, NFPA 90A, NFPA 72

This deficiency affected one smoke compartment.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0341

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.

Reference 2012 NFPA 101 Section 21.3.5.2, 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.

This deficiency affected all smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0352

1. The corridor door to clean utilities room had penetrations around the handle where the latching device had been replaced. THe door was not smoke tight to resist the passage of smoke.

Reference 2012 NFPA 101 21.3.7.1 (2) Doors shall be constructed of not less than 1-3/4" thick, solid-bonded wood core or the equivalent and shall be equipped with positive latches. Reference 2012 NFPA 101 19.6.3.2 (2) The door shall be constructed to resist the passage of smoke, 4.6.12.4 CMS S&C 07-18.

This deficiency affected one smoke compartment.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0363

The following smoke barrier walls had failed or had improperly firestopped penetrations. The smoke barrier has penetrations that were not sealed or sealed with an unapproved sealant and need to be repaired/ sealed to provide a UL approved fire stop application.

1. Inside sterile storage there were unsealed penetrations.
2. Inside the OR suite above the housekeeping room there were unsealed penetrations.
3. Behind the refrigerator at the nurses station there were unsealed penetrations.
4. Above the monitor in the hall there were unsealed penetrations.

Reference 2012 NFPA 101 21.3.7.1 (1) Walls shall have not less than a 1-hour fire resistance rating and shall extend from the floor slab below to the floor or roof slab above.
Reference 2012 NFPA 101 Sections, 8.5, 8.5.6.2, 8.5.6.3, 8.5.6.5
Reference 2012 NFPA 101 Sections, 4.1.1, 4.2.3, 4.5.8, 4.6.12.2, 4.6.12.4, 43.5.1.3
Reference 2012 NFPA 101 Sections 9.1.2
Reference 2011 NFPA 70 Articles 300-21, 760-3(a), 820-26, 830-26
Reference 2012 NFPA 101 4.5.8 Smoke barriers shall be constructed to a 1/2-hour fire resistance rating.

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

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0372

1. The door in the smoke barrier wall to the MD's Lounge had been removed.

Reference 2012 NFPA 101 21.3.7.1 (2) Doors shall be constructed of not less than 1-3/4" thick, solid-bonded wood core or the equivalent and shall be equipped with positive latches. 4.6.12.4 CMS S&C 07-18.

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

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0374

Building 0307: Women's Center

1. In the rated fire/smoke wall above the corridor doors between the NICU unit and outside the electrical room C there are two 4 inch conduit penetration with electrical cables running through them and the opening in the inside of the conduit wall and electrical is not sealed in order to maintain the required rating of the wall.

Reference NFPA 101: Table 19.1.6.1, unless otherwise permitted by NFPA 101: 19.1.6.2 through 19.1.6.7; 19.1.6.4, 19.1.6.5 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, or other features shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.
2012 NFPA 101: 19.7.6; 4.6.12.1

This deficiency affected one smoke compartment and one horizontal exiting corridor.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0161

1. The corridor doors to IT rooms HUB 63 and 64 have louvers installed in the lower half of the doors and would not resist the passage of smoke.
2. The facility failed to maintain the latches and smoke resistance of doors protecting corridor openings. Doors to the following patient room did not close/latch/seal tightly in their frames; NICU doors 18 and 12.

Reference NFPA 101: 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Reference 2012 NFPA 101 19.6.3.2 (2) The door shall be constructed to resist the passage of smoke, 4.6.12.4 CMS S&C 07-18.

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

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0363

The following electrical outlets located near sinks were not GFCI protected.
1. W1NLE-B9 Nurse Station Middle Station
2. W1NLF-B14 Med Room North
3. W1NLE-B15 North Nourishment Room
4. W1CEF-A23 Commercial Ice Machine
5. Clean supply room sink

Reference 2012 NFPA 19.5.1.1, 9.1.1, 9.1.2, NFPA 70, National Electric Code

This deficiency affected the entire.
Failure to comply with minimum standards as referenced increases the risk of death due to electrical shock.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0511


Building 0507: The Summitt

1. There was not a closure on the soiled linen room, exceeding 64 gallons, in the Imaging Center.
2. There was not a closure on the soiled linen room, exceeding 64 gallons, in the Pain Clinic.

Reference 2012 NFPA 101 39.3.3.2 (1) The area shall be separated from other parts of the building by fire barriers having a minimum 1-hour fire resistance rating, with all openings therein protected by self-closing fire door assemblies having a minimum 3/4 hour fire protection rating.

This deficiency affected hazardous area and adjacent areas.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0321

1. This facility is 100% sprinklered per NFPA 13. The sprinkler heads located in the imaging area were not maintained clean and in good condition. Sprinkler heads were covered in dust and lint at the time of the survey.

Reference 2012 NFPA 101 39.3.5, 9.7.5, 4.6.12.1, 2011 NFPA 25.5.4.1.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, or other features shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.

This deficiency affected one smoke compartment.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0353


Building 0607: Mount Holly Emergency Department


1. This facility is 100% sprinklered per NFPA 13. 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 sprinkler control valve was moved from the normal open position to closed position.

Reference 2012 NFPA 101 Section 20.3.5.2, 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.

This deficiency affected the entire facility.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0352

1. This facility is 100% sprinklered per NFPA 13. At the time of the survey documentation could not be provided for the (3) three year flow test.

Reference 2012 NFPA 101 20.3.4, 9.7.5, 4.6.12.1, 2011 NFPA 25.5.4.1.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, or other features shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.

This deficiency affected the entire facility.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0353

1. There was a flex cable in the smoke wall by room 1216, the results room, that the penetration had not been sealed properly.

Reference 2012 NFPA 101 20.3.7.1 (1) Walls shall have not less than a 1-hour fire resistance rating and shall extend from the floor slab below to the floor or roof slab above.
Reference 2012 NFPA 101 Sections, 8.5, 8.5.6.2, 8.5.6.3, 8.5.6.5
Reference 2012 NFPA 101 Sections, 4.1.1, 4.2.3, 4.5.8, 4.6.12.2, 4.6.12.4, 43.5.1.3
Reference 2012 NFPA 101 Sections 9.1.2
Reference 2011 NFPA 70 Articles 300-21, 760-3(a), 820-26, 830-26
Reference 2012 NFPA 101 4.5.8 Smoke barriers shall be constructed to a 1/2-hour fire resistance rating.

This deficiency affected the entire facility.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0372

1. Oxygen storage was within five feet of combustibles.

Reference 2012 NFPA 101 20.3.2.3, 99 11.3.2.3 Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following: (1) Minimum distance of 6.1 m (20 ft) (2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13.3 Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/2 hour.

This deficiency affected one smoke compartment.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0923

Building 0707: Lincoln Radiation Center

1. Upon testing the Fire Alarm Control Panel (FACP) it was discovered that when the sprinkler control valve at the backflow preventor located outside was moved out of the normal position it provided a supervisory signal at the (FACP) but transmitted a general fire alarm to the monitoring company in place of sprinkler supervisory alarm.

Reference NFPA 101 39.3.4, 4.6.12.1; 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, or other features shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.

This deficiency affected the entire facility and fire alarm panel..
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0345

1. This facility is 100% sprinklered per NFPA 13. 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 sprinkler control valve was moved from the normal open position to closed position at the backflow preventor located outside.

Reference 2012 NFPA 101 Section 39.3.4, 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.

This deficiency affected the entire facility.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0352