|Multiple Occupancies - Construction Type|
Where separated occupancies are in accordance with 18/126.96.36.199 or 18/188.8.131.52, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 184.108.40.206, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/220.127.116.11
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.104.22.168, 22.214.171.124, 126.96.36.199
Name: WESTMORELAND - Component: 01 - Tag: 0133
Based on observation and interview, it was determined the facility failed to maintain common wall doors to be within the allowed gap margins, at three of seven common wall doors within the component.
1. Observation on December 26, 2019, between 11:50 AM and 12:05 PM, revealed common wall doors had gaps exceeding one eighth of an inch, at the following locations:
a. 11:50 AM, double corridor fire rated doors separating the Nursing Care from the Core Building, off the Main Lobby;
b. 12:00 PM, fire rated door separating the Nursing Care from the Core Building, at the Dish Room 212C, off the Main Lobby;
c. 12:00 PM, separating the Nursing Care from the Core Building, at the Dish Room 212C, off the Main Lobby;
d. 12:05 PM, separating the Nursing Care from the Core Building, at the Electrical Room 212B, off the Main Lobby.
Interview with the Plant Operations Manager on December 26, 2019, at 12:05 PM confirmed the common wall doors exceeded the allowed gap margins.
| ||Plan of Correction - To be completed: 02/24/2020|
All four doors will be repaired to ensure that all gaps are less than one eighth inch by February 24, 2020. The Facilities Director will ensure that this work is completed.
In order to ensure that this deficiency does not reoccur, the 4-12 Night Watchman will monitor all rated and common wall doors in Westmorland (and between Westmorland and other areas) during his rounds, and take appropriate action and follow up if any are found to have gaps greater than 1/8 inch. He will document compliance daily for 30 days and then weekly for 2 months. After that time, documentation will be completed monthly for 9 months.
The Facilities Director will share the data collected with the Administrator and the compliance rate will be reported (monthly, for 12 months) to our Quality Assurance Performance Improvement Committee by the Administrator.