|Vertical Openings - Enclosure|
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
22.214.171.124 through 126.96.36.199
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0311
Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of vertical openings in four instances in three of four vertical openings in the facility.
1. Observation on April 19, 2019, revealed the fire resistance rating in the following locations was not maintained:
a) 9:45 a.m., there was an 8"x5" opening in the elevator shaft on the first floor, in the space between the cars;
b) 11:50 a.m., there was an 8"x8" hole in the North Stairwell on the third floor, in front of the access panel;
c) 11:55 a.m., there were two holes, aproximately 1 foot square in the North stairwell on the second floor, in front of the access panel;
d) 11:59 a.m., there was a section of the second floor South Stairwell, approximately 16"x36", that was incomplete to the deck above. Observed from the adjacent Nutrition Room.
Interview with the Administrator, Director of Nursing and Maintenance Supervisor on April 29, 2019, at 1:00 p.m., confirmed the vertical opening deficiencies.
| ||Plan of Correction - To be completed: 06/05/2019|
The Maintenance Director/designee will ensure that the identified penetrations are filled and have a fire resistance rating of at least 1 hour.
Maintenance Director will be educated on the need for stairways, elevator shafts, light and ventilation shafts, and other vertical openings between floors to be enclosed with construction having a fire resistance rating of at least 1 hour by the Administrator/designee.
The Maintenance director/designee will complete weekly audits x4 randomly of vertical shaft penetrations to ensure they have a fire resistance rating of at least 1 hour. Results of these audits will be forwarded to the QAPI committee for review and recommendation.