Failure to Maintain Fire Resistance of Stairtower Enclosures
Penalty
Summary
The facility failed to maintain the fire resistance of exit stairtower enclosures, specifically affecting one of eleven smoke compartments. During an observation, it was noted that the basement door to Stairtower 1 did not positively latch within the door frame. This deficiency was confirmed through an interview with the Facilities Director, who acknowledged the issue with the stairtower door not latching properly.
Plan Of Correction
1. The Maintenance Director/designee will repair or replace the basement door to Stair Tower 1 to ensure it positively latches within the door frame, maintaining the fire resistance of the exit stair tower enclosure. 2. The Maintenance Director and relevant staff members will receive training on NFPA 101 Standard - Stairways and Smokeproof Enclosures, focusing on the importance of maintaining the fire resistance of exit stair tower enclosures and ensuring proper door functionality. 3. The Maintenance Director/designee will inspect all stair tower doors within the facility to verify they positively latch within the door frame and maintain the required fire resistance. Monthly audits of stair tower doors will be conducted to ensure continued compliance with positive latching requirements. 4. Findings will be reviewed at the Quality Assurance Performance Improvement meeting.