Inaccessible Hazardous Area Prevents Fire Safety Verification
Penalty
Summary
Staff were unable to provide access to a supply storage room located in the service hall between storage rooms 11 and 12 during an observation on 03/25/2025 at approximately 12:20 PM. This prevented a full inspection of the area to verify whether it was properly protected by a fire barrier with a 1-hour fire resistance rating, equipped with 3/4 hour fire rated doors, or safeguarded by an automatic fire extinguishing system as required by regulation. The inability to access the room meant that surveyors could not confirm compliance with fire safety standards for hazardous areas. This deficiency was confirmed through an interview with Facility Maintenance at the time of observation. The report specifically notes that this practice could affect 20 occupants in the event of a fire emergency, as the lack of access hindered the ability to ensure the hazardous area was adequately protected.
Plan Of Correction
Rounds being conducted during the Annual State Survey, the Maintenance director was unable to make entry into the supply closet located between rooms 11 and 12 in the service hallway, in turn not being able to ensure the automatic-closing door or the presence of an automatic fire extinguishing system, which put 20 occupants at risk. The maintenance director adjusted the door to the supply closet between rooms 11 and 12 to ensure the door would open freely with key access. The Maintenance director confirmed that the door was an automatic-closing door and was functioning properly, and there was an automatic fire extinguishing system present inside the closet. The maintenance director did a complete facility round to ensure safeguards were in place. The maintenance director was educated on K321 tag to ensure proper access to the facility, to ensure areas are protected with a fire-rated door or an automatic fire extinguishing system, and to ensure all safeguards are in place. The Maintenance director will complete bi-weekly facility rounds to ensure safeguards are in place and that all doors are functioning properly. Concerns will be addressed at the time of observation. Results of the facility rounds will be reported in QAPI monthly for 3 months. The Administrator is responsible for maintaining compliance.