Unsealed Openings in Elevator Shaft
Penalty
Summary
During a Life Safety Code Survey conducted from February 11 to February 19, 2025, a deficiency was identified on the first floor of a long-term care facility. The facility failed to properly maintain vertical openings, specifically within a fire-rated enclosure of an elevator shaft. Observations made on February 11, 2025, at 10:48 AM revealed unsealed openings in the elevator shaft located in the first-floor elevator equipment room. These included two approximately 1/2-inch by three-inch openings around electrical raceways and two approximately 1/2-inch by three-inch semi-circular openings around hydraulic lines. These openings extended through the concrete block wall into the elevator shaft. The facility has two elevators serving the first, second, and third floors. During an interview, a Maintenance Staff Member mentioned that some upgrades to the elevators had been completed a couple of months prior to the survey.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 1. Facility conducted an immediate inspection on all vertical openings in the elevator shaft on 02/12/2025. All unsealed openings were sealed immediately by facilities staff using fire rated materials on 02/12/2025. 2. Maintenance performed a facility wide audit of all openings to identify any additional unsealed openings. All openings were sealed by facilities staff. 3. Education will be provided to all pertinent staff regarding the importance of sealing any needed openings/penetrations in fire walls. 4. A monthly audit of fire wall penetrations will be conducted monthly for three months. A copy of the audits will be presented to QAPI committee who will then decide the needed frequency of the audits thereafter. Responsible Party: Director of Facilities