Failure to Maintain Fire Resistance Rating in Facility
Penalty
Summary
The facility failed to maintain a two-hour fire resistance rating to separate buildings of different construction types, specifically between the main building and the west wing. This deficiency was identified during an observation on February 3, 2025, when it was noted that the door between these two areas did not latch properly in its frame when tested. This issue affects one of the twenty-six smoke compartments within the facility. The deficiency was confirmed through an interview with the Facility Administrator and Maintenance Director on February 4, 2025, at 2:00 p.m. They acknowledged the problem with the doors in the two-hour rated occupancy separation wall, which is a requirement under NFPA 101 for maintaining fire safety standards in health care facilities. The failure to ensure proper latching of the door compromises the intended fire resistance rating, which is crucial for the safety of the facility's occupants.
Plan Of Correction
131 1. The Door between west wing and main building was corrected to securely latch in its frame. 2. An ongoing audit is conducted and reviewed by the Director of maintenance or Designee to assess doors across the campus to ensure they latch to their frame. 131 main 2 1. The Door between west wing and main building was corrected to securely latch in its frame. 2. An ongoing audit is conducted and reviewed by the Director of maintenance or Designee to assess doors across the campus to ensure they latch to their frame.