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K0161
D

Compromised Fire Resistance Rating of Structural Steel

York, Pennsylvania Survey Completed on 03-06-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain the required 2-hour fire resistance rating of structural steel beams, which affected one of the 27 smoke compartments within the building. During an observation on March 5, 2025, at 11:15 AM, it was noted that approximately four inches of structural steel were exposed above the suspended ceiling in the 5th floor alcove near Resident Room 540. This exposure compromised the fire resistance rating of the structural steel member. The Facilities Manager confirmed the deficiency during an interview conducted at the same time.

Plan Of Correction

1. The four inch structural steel above resident room 540 was covered with Universal Fireproofing Patch that provides a minimum 2-hour fire resistance coating. 2. The maintenance department will be in-serviced by NHA/Designee on the importance of having the structural steel of the facility being coated with a minimum of a 2-hour fire resistant material. 3. Quarterly audits will be performed by the maintenance director/ designee in random locations to ensure there is a minimum 2-hour fire resistant protectant on the structural steel of the facility. 4. Results of the audit will be reviewed/reported to the QA committee to determine trends and compliance. QA committee will determine need for continuance of audits.

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