Failure to Maintain Vertical Opening Enclosures
Penalty
Summary
The facility failed to maintain proper vertical opening enclosures, as evidenced by an observation on February 6, 2025. During the inspection, it was noted that floors five and seven, which were unoccupied at the time, had multiple unsealed openings in a bathroom pipe chase wall. These openings were present due to ongoing work to replace a leaking drain pipe. This deficiency affected two out of twelve smoke compartments in the facility. The issue was confirmed through an interview with the Facility Administrator and Maintenance Director on the same day.
Plan Of Correction
Unsealed openings on floors 5 and 7 will be repaired by 3/21/2025. House audit will be completed by Maintenance Director or designee on unsealed openings. The administrator or designee will reeducate Maintenance Director on unsealed openings - K311. Identified rooms will be inspected for new openings monthly by the Maintenance Director or designee. Findings will be reported to Quality Assurance and Performance Improvement committee meetings.