Vertical Openings - Enclosure 2012 EXISTING Vertical openings shall be enclosed or protected per 8.6, unless one of the following conditions exist: 1. Unenclosed vertical openings per 8.6.9.1 are permitted. 2. Unenclosed openings which do not serve as a required means of egress are permitted. 3. Exit access stairs may be unenclosed if they meet the following conditions: Two stories or less a. Building is protected throughout by a supervised sprinkler system per 9.7.1.1(1). b. Total travel distance to outside does not exceed 100 feet. Three stories or less a. Occupant load per story does not exceed 15 people. b. Building is sprinkler protected throughout per 9.7.1.1(1). c. Building contains an automatic smoke detection system per 9.6. d. Activation of the sprinkler system or smoke detection system notifies all occupants of the building. e. Total travel distance to outside does not exceed 100 feet. Floors that are below the street level and are used for storage or any use other than a business occupancy, shall not have any unprotected openings to the business occupancy floors. 21.3.1, 39.3.1.1, 39.3.1.2
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Observations: Name: CLASS B & C ASF - Component: 01 - Tag: 0311 Based on observation and interview, the facility failed to maintain the fire resistance rating of vertical penetrations, affecting one of two levels.
Findings Include:
1. Observation on September 13, 2023, at 10:30 am, revealed, basement mechanical room had an unknown expanding foam product installed around existing penetrations.
Exit Interview with the Administrator and Director of Nursing on September 13, 2023, at 10:50 am, confirmed the unknown foam substance.
| | Plan of Correction - To be completed: 10/31/2023
Contractors have been contacted to remove the improperly installed expanding foam product from existing penetrations. The existing penetrations will then have approved and appropriate fire caulk installed. The work shall be completed no later than October 31, 2023. On a semi-annual basis, the administrator, director of nursing or designee will verify that there is no expanding foam product and that any penetrations will have appropriate fire caulk installed. Findings from these visual audits will be documented and reported to the Medical Advisory Board and Governing Body through the end of Quarter 4 2024.
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