Improper Fire Resistive Material in Soiled Linen Room
Summary
The facility failed to ensure that the soiled linen room was protected with proper fire resistive material. During a life safety survey conducted over two days, a penetration in the hydraulic motor room located in the basement was observed. This penetration consisted of a 1ft x 1ft area wall cut out filled with pink fiberglass material, which is not an appropriate fire/smoke sealant. The Maintenance Director acknowledged the issue and indicated that the material would be removed and replaced with suitable fire/smoke sealant.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 I. Immediate Corrective Action Maintenance filled the hole on 3/28/25 with concrete. II. Identification of Other Residents The facility respectfully states that residents could potentially be affected by this deficient practice. The maintenance department inspected the entire building to ensure compliance. No outstanding issues were noted. III. Systemic Changes The Maintenance department was in-serviced about Hazardous Areas - Enclosure. Maintenance will inspect all areas after any construction work is done. Responsible Party: Director of Maintenance
Penalty
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