Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9
Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
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Observations:
Name: MAIN - Component: 01 - Tag: 0321
Based on observation and interview, it was determined the facility failed to maintain hazardous area doors to self-close, to have fire-rating label and for fire rated labels to be legible, on one of three floors within the component.
Findings include:
1. Observation on June 23, 2026, between 11:40 AM and 11:45 AM, revealed hazardous area doors failed to self-close, at the following locations:
a. 11:40 AM, basement, Central Supply Room double doors, left leaf, faulty coordinator;
b. 11:45 AM, basement, Mechanical Room double doors, left leaf, faulty coordinator.
Interview with the Administrator and Maintenance Director on June 23, 2026, at 1:45 PM, confirmed the doors failed to self-close.
2. Observation on June 23, 2026, between 11:33 AM and 12:08 PM, revealed fire rating labels were removed at the following locations:
a. 11:33 AM, basement, Mechanical Room door, left leaf;
b. 11:47 AM, basement, Storage Room door, left leaf;
c. 12:06 PM, basement, Clean Linen Room door;
d. 12:08 PM, basement, Soiled Linen Room door, right leaf.
Interview with the Administrator and Maintenance Director on June 23, 2026, at 1:45 PM, confirmed fire-rated labels were missing.
3. Observation on June 23, 2026, at 12:09 PM, revealed the basement Soiled Utility Room, left leaf, fire-rating label was obscured.
Interview with the Administrator and Maintenance Director on June 23, 2026, at 1:45 PM, confirmed fire-rated label was not legible.
| | Plan of Correction - To be completed: 07/27/2026
1. A Time-Limited Waiver(TLW) through September 30, 2026 has been requested for the cited hazardous area door deficiencies while replacement parts are on order. A copy of the Time-Limited Waiver request has been submitted to the Field Office.
2. Maintenance staff were educated on hazardous area door requirements. Until repairs are completed, the affected doors will remain closed when not in use and will be monitored to ensure resident and staff safety.
3. The Maintenance Director will conduct on going monthly audits of the affected hazardous area doors until repairs are completed. Findings will be reported to the QAPI Committee.
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