Unsealed Pipe Penetration in Fire-Rated Wall
Penalty
Summary
The facility failed to maintain a two-hour occupancy separation barrier as required by NFPA 101 standards. During an observation on December 4, 2024, at 9:27 a.m., a surveyor identified an unsealed pipe penetration in the two-hour fire-rated occupancy separation wall above the doors on the first floor. This deficiency was confirmed during an interview with the Facility Administrator, Regional Nursing Consultant, and Maintenance Assistant later that morning at 11:30 a.m. The unsealed penetration compromised the integrity of the fire-rated barrier, which is essential for maintaining the required separation between different occupancies within the building.
Plan Of Correction
The facility cannot retroactively correct the concern of an unsealed pipe penetration in the two-hour fire rated occupancy separation barrier in one of two floors. The area identified was corrected prior to end of survey. Audit has been completed on all other areas of the facility. No further unsealed pipe penetration has been noted. Nursing Home Administrator (NHA)/Designee will educate maintenance staff on fire rated separation barriers. Maintenance Staff/Designee will audit fire rated separation barriers 5 times per week for 2 weeks, then weekly for 2 weeks, then monthly for 2 months to ensure there are no unsealed pipe penetrations. The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review.