Fire Resistance Deficiencies in Hazardous Areas
Penalty
Summary
The facility failed to maintain the fire resistance rating of hazardous areas in sprinklered locations, affecting two of four levels. On the third floor, an unsealed penetration around a copper pipe was observed in the resident storage room D3091, and the electrical transformer room door lacked a self-closer. Additionally, on the second floor, combustible boxes were found laying atop an electrical transformer in the kitchen dry storage area. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director.
Plan Of Correction
The facility should maintain the fire resistance rating of hazardous areas in sprinklered locations in all levels of facility. Per fire safety guidelines, fire caulk: 3M Fire Barrier Sealant CP 25WB+ was installed on the third-floor South resident storage room D3091 for unsealed penetration around copper pipe. The second-floor electrical transformer room door self-closer has been installed. The combustible boxes laying on top of electrical transformer in the second-floor kitchen dry storage have been removed. Staff education has been provided to ensure compliance. Audits will be conducted once a week for 4 weeks, bi-weekly for a month to ensure compliance. Staff education completed on 12-30-2024. The Facilities Director or designee will bring such audits to the QA meeting monthly x3 in order for the QA team to verify compliance.