|Building Construction Type and Height|
Building construction type and stories meets Table 188.8.131.52, unless otherwise permitted by 184.108.40.206 through 220.127.116.11
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered
2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered
3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)
7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161
Based on observation and interview, the facility failed to maintain building construction, within a one hour fire rated ceiling assembly, at one of eleven wings.
1. Observation on January 30, 2019, at 11:20 a.m., revealed the second floor, corridor recessed ceiling light fixture, located between the smoke barrier and the lounge, lacked proper bonneting to maintain the fire rating of the ceiling assembly.
Interview with the maintenance director on January 30, 2019, at 11:20 a.m., confirmed the above recessed ceiling light lacked required bonneting.
| ||Plan of Correction - To be completed: 03/15/2019|
1. Light fixture will have bonneting installed and made to be complete.
2. The maintenance director/designee will ensure bonneting is in place for all like fixtures.
3. The maintenance director/designee will do random audits of light fixtures throughout the facility to make sure that they remain in regulatory compliance. Any trends will be reported in Quality Assurance and Performance Improvement committee for further action and planning, if necessary