Unprotected Structural Components in Facility
Penalty
Summary
Structural components of the facility were not properly protected from fire, as observed during the Life Safety Code survey. The structural support web truss system and steel beams located above the lay-in style ceiling assembly were not protected to meet the minimum acceptable fire-rated building construction classification. This deficiency affected all three resident use floors in the front building. The facility's construction type requires that structural components be protected by a one-hour or two-hour fire-rated barrier, depending on the specific classification. However, observations revealed that the ceiling tiles on the first, second, and third floors were comprised of an unrated lay-in ceiling assembly, and there were unprotected structural steel beams and steel web truss assemblies. During an interview, the Assistant Maintenance Director confirmed that there had been no changes to these components since the last Life Safety Code survey.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 The facility had an FSES completed prior which indicated that the facility was in compliance with NFPA [PHONE NUMBER] 19 1.6.1 equivalency. However, due to the passage of time, the facility will be conducting a new FSES to be performed in accordance with CMS survey and certification memo 17-15-LSC. The FSES will be started on 3/10/25. All residents had the potential to be affected. No other life safety functions were affected. The facility will in-service the maintenance director on fire safety maintenance such as identification of any potential fire safety concerns or potential for unsafe or hazardous conditions. The Maintenance Director will be educated on the results of the FSES and on the requirement to ensure the facility is in compliance with NFPA [PHONE NUMBER] 19 1.6.1. The facility also intends to maintain compliance by utilizing an FSES for equivalency as necessary for future recertifications as applicable. An audit tool was created to ensure all items listed in the upcoming FSES are in place. Audits will be conducted monthly x4. The results of the FSES, the requirement for a passing FSES, and the results of the audits will be discussed at QAPI. The Administrator/Designee is responsible for this plan.