Deficient Fire Separation in Facility Occupancies
Penalty
Summary
The facility failed to ensure that sections of health care facilities classified as other occupancies were properly separated from areas of healthcare occupancies by construction with a two-hour fire resistance rating. This deficiency was identified during observations and interviews conducted on December 19, 2024. Specifically, the separation between the Healthcare occupancy and the Residential occupancy was compromised by a 1.5-inch and 2.5-inch unprotected penetration for wire pass-throughs. Additionally, a 2-inch-high by 48-inch-wide section of brick was missing above the fire-rated door assembly between the two occupancies. These observations were confirmed by the USTFOTAT at the time of the inspection. The facility's representative was informed of these deficient practices during the Life Safety Code exit conference on December 20, 2024.
Plan Of Correction
1/9/25 1. All residents have the potential to be affected by this deficient Life Safety Code. The maintenance department repaired the 2 unprotected penetrations for the pass-through of wires on 1/8/25 using UL listed NUEX Order 26.4(DX LC 150 fire-stop sealant. The maintenance department repaired the 2 inch by 48 inch wide section of brick missing above the fire rated door assembly between the two occupancies on 1/8/25 using intumescent fire-stop pillows and UL listed NJ Ex Order 26.4(15) LC 150 fire-stop sealant. 2. The facility's maintenance schedule will be revised by the Director of Maintenance to include a monthly inspection of fire-rated assemblies between the healthcare occupancy and the residential occupancy to confirm that the two hour fire resistance rating is intact with no penetrations using an audit tool. 3. The Director of Maintenance will review the fire rated assembly inspection reports monthly ongoing and report the results to the administrator and to the QAPI committee monthly for 6 months.