Unprotected Steel Beams Found in Facility
Penalty
Summary
During a life safety survey, it was observed that the facility did not maintain all structural components to meet the requirements for a Type II (222) building construction. Specifically, unprotected steel beams were found on the first floor landing of the East stair and in the garage attached to the building, which is accessible from the first floor. These findings indicate a failure to comply with the construction type limitations as outlined in the 2012 NFPA 101 standards, which require complete automatic sprinkler protection for buildings of this type.
Plan Of Correction
Plan of Correction: Approved April 17, 2025 K 161- Automatic Sprinkler Protection I. IMMEDIATE CORRECTIVE ACTION: A licensed Contractor was hired to encapsulate the exposed, unprotected steel beams with the approved 2-hour NFPA material. II. IDENTIFICATION OF OTHERS AFFECTED: All residents have the potential to be affected. In order to ensure full compliance of this standard throughout the facility, all beams were assessed. None were found deficient at this time. III. SYSTEMIC CHANGES: A Monthly Compliance Audit of affected/corrected beams will begin (MONTH) 2025. These monthly audits will continue for a period of 3 months with results reported by the Director of Maintenance to the facility QAPI Committee. Any negative findings will be immediately reported to the Director of Maintenance and corrected. IV. QAPI MONITORING: The findings of the above noted compliance audit will be reported to the facility Quality Assurance and Performance Improvement Committee monthly for 3 months by the Director of Maintenance. Any trends or concerns that may be identified will be discussed by the committee and any interventions will be implemented. The QAPI Committee will determine the need for ongoing reporting. Completion Date: 05/30/2025 Responsible Party: Director of Maintenance