Deficiencies in Hazardous Area Enclosures
Penalty
Summary
The facility failed to ensure that all hazardous areas were properly enclosed in accordance with the 2012 NFPA 101 standards. During a life safety survey, several deficiencies were observed on the first floor. In the generator room, a plywood wall covering was not labeled as fire-resistant, and there was a large opening in the concrete wall that communicated with the adjacent automatic transfer switch room. Additionally, the door to this room was propped open. The automatic transfer switch room lacked sprinkler coverage, had missing ceiling tiles exposing unprotected steel beams, and wall penetrations were sealed with non-approved fire blocking foam. The trash compactor room door was not self-closing and lacked a latch due to missing hardware. Similarly, the boiler room door was missing hardware, allowing smoke to pass into the corridor. Lastly, the maintenance shop room door was held open with a magnet not connected to the fire alarm system.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 Element 1 K321 Corrective Action: The maintenance director immediately audited all areas within the building to ensure any hazardous area has a 1-hour fire resistance rating, and the areas shall be separated from other spaces by smoke partitions in accordance with 2012 edition of NFPA 101. The following corrections have been made: On 12/20/2024, the concrete wall surrounding the generator room had an opening of 3-4', communicating with the adjacent transfer switch room. This area has been sealed with concrete blocks to comply with a 1-hour fire rating. The tiles missing in the automatic transfer switch room were replaced. On (MONTH) 13, 2025, the door to the trash compactor room had the hardware replaced to include a panic bar door handle and latch to ensure the door was self-closing. On (MONTH) 13, 2025, the hardware on the boiler room door was replaced to ensure it was self-closing and did not allow the penetration of smoke. All penetrations in the walls that were sealed with fire blocking foam have been removed and replaced with an approved fire rated stopping material. Element 2 Residents at Risk: While no other residents were affected by this practice, the potential existed for all residents and staff to be affected by this practice. All hazardous areas were inspected for similar deficiencies. None were found. Element 3 The policy and procedure for hazardous doors was reviewed and revised. All maintenance staff will be in-serviced on 2012 NFPA 101 19.3.2.3 hazardous areas shall be safeguarded with a 1-hour fire rating. Documentation checklist for Life Safety Code Standards Observations will be implemented and include all components of hazardous areas shall be safeguarded by a fire barrier having a one-hour resistance rating. Any negative findings will be addressed immediately. An audit tool was developed to monitor compliance. Element 4 Monitoring of Corrective Action: The maintenance director or designee will inspect all Hazardous Areas to ensure all areas are safeguarded by a fire barrier having a 1-hour fire resistive rating. The findings of all these audits to inspect all Hazardous Areas to ensure a 1-Hour Fire Rating will be reviewed monthly and reported to the Administrator. The maintenance director or designee will report findings to the QAPI Committee quarterly for a period of 6 months. The QAPI Committee will determine any further actions. Element 5 Person Responsible: Maintenance Director