Failure to Maintain Fire Resistance in Common Wall Separations
Penalty
Summary
The facility failed to maintain fire resistance in common wall fire separations within one of its components. During an observation on January 27, 2025, between 9:05 a.m. and 9:45 a.m., it was noted that certain fire-rated doors did not positively bottom latch when tested. Specifically, at 9:05 a.m., the double doors on the first floor at Tony's Café, which separate Component 1 from Component 2, failed to latch. Additionally, at 9:45 a.m., the level fire door in the basement, also separating Component 1 from Component 2, did not latch properly. This deficiency was confirmed during an exit interview with the Facility Administrator and Director of Maintenance.
Plan Of Correction
The doors and door hardware will be adjusted so the door will positively latch into the frame. We will continue to inspect for these conditions on our monthly environmental rounds for compliance. The Director of Maintenance will be responsible for maintaining compliance of this inspection.