Deficiency in Hazardous Area Enclosure
Penalty
Summary
The facility failed to maintain hazardous area enclosures as required by NFPA 101 standards. During an observation on December 30, 2024, at 11:45 a.m., a penetration was found in the ceiling of the Janitor's closet located in the Memory Care Unit. This deficiency was confirmed through an interview with the Facility Administrator and the Maintenance Director later that day at 1:30 p.m. The issue affected one of the eight smoke compartments in the facility, indicating a lapse in maintaining the required fire barrier protection for hazardous areas.
Plan Of Correction
NHA/Designee will educate the Maintenance Director/Maintenance staff on the NFPA requirements for hazardous area - corridors. The penetration in the ceiling of the janitor's closet in the Memory Care Unit was fixed on 1/8/25. A visual inspection of all of the facility's janitor's closets will be completed to ensure no more penetrations are present.