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Tag No.: K0161
Based on observations, and documentation review on 11/15/2016, at approximately 10:00 AM onward, the following deficiencies were noted: The facility maintenance and inspection of rated walls was non-compliant, specific findings include:
The facility has unsealed penetrations at the back of the rated wall in the environmental services room 5E148 where electrical conduits protrude through the block wall.
Ref: 2012 NFPA 101 Section 19.1.6.1; 8.3.5.1
This deficiency affects one of one smoke zones in the facility.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.
Tag No.: K0345
Based on observations, and documentation review on 11/15/2016, at approximately 10:00 AM onward, the following deficiencies were noted: The facility maintenance and inspection of the Fire Alarm Control Panel (FACP) components was non-compliant, specific findings include:
During the inspection and testing of the FACP that consisted of multiple components the loss battery back up power was tested. There was not a visual nor audible trouble notification that the battery back up power for the FACP was disconnected.
Ref: 2012 NFPA 101 Section 19.3.4.1; 9.6.1.3
This deficiency affects the entire facility.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke
Tag No.: K0521
Based on observations, and documentation review on 11/15/2016, at approximately 10:00 AM onward, the following deficiencies were noted: The facility maintenance and inspection of air handler shut down switches was non-compliant, specific findings include:
The facility emergency air handler shut down switch was tested during the survey. During that test the emergency air handler shut down switch did not shut off power to the air handler serving the unit.
Ref: 2012 NFPA 101 Section 19.5.2.1; 9.2.1
This deficiency affects one of one smoke zones in the facility.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.