Hazardous Areas - Enclosure 2012 New Hazardous areas are protected in accordance with 18.3.2.1. The areas shall be enclosed with a 1-hour fire-rated barrier, with a 3/4-hour fire-rated door without windows (in accordance with 8.7.1.1). Doors shall be self-closing or automatic-closing in accordance with 7.2.1.8. Hazardous areas are protected by a sprinkler system in accordance with 9.7, 18.3.2.1, and 8.4. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 18.3.2.1, 7.2.1.8, 8.4, 8.7, 9.7
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 and less than 100 square feet) g. Combustible Storage Rooms/Spaces (over 100 square feet) h. Laboratories (if classified as Severe Hazard - see K322)
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Observations: Name: NEW FACILITY - Component: 10 - Tag: 0321
Based on observation and interview, it was determined the facility failed to maintain hazardous area doors to be self-closing, affecting one of three smoke compartments within the component. Findings include:
1. Observation on March 11, 2024, at 11:45 AM, revealed the Kitchen Dry Storage Room door, with a fire-rating label, was held open with cardboard wedge under the door.
Interview at the time of the exit conference with the Administrator, Director of Maintenance on March 11, 2024, at 1:30 PM, confirmed the fire-rated door was wedged open.
| | Plan of Correction - To be completed: 04/09/2024
The maintenance director immediately removed the cardboard wedge from blocking the door.
The maintenance director and NHA toured the facility to ensure no other doors were being blocked open by inappropriate means.
The dietary staff will be reeducated to the need to ensure fire doors are closed or have the means to close on their own. They will be reeducated to the requirement to not block doors open.
The maintenance director or designee will audit the kitchen two times per week to ensure that fire doors are closed or have the ability to close during an emergency. Findings will be submitted to the quality assurance committee for review and input.
Plan of correction date is April 9, 2024
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