Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5
Construction Type
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.
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Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0161
Based on observation and interview, it was determined the facility failed to maintain common wall doors to be free of impediments to close, in one of three smoke compartments within the component.
Findings include:
1. Observation on April 17, 2025, at 1:00 PM, revealed the common wall door, from the Kitchen, was held open by a plastic wedge and could not close and latch.
Interview with the Director of Maintenance on April 17, 2025, at 1:00 PM, confirmed the common wall door was wedged in the open position and could not close.
| | Plan of Correction - To be completed: 05/15/2025
The statement/s made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiency/s herein.
To remain in compliance with all Federal and State regulations, the facility has taken and will continue to take the actions set forth in the following plan of correction.
The following plan of correction constitutes the center's allegation of compliance. The alleged deficiency cited has been / or will be corrected by the date/s indicated.
The facility is committed to taking all actions necessary to remain in substantial compliance with the Federal and State regulations.
The plan of correction addresses our intentions to promote care for our residents which enhances their dignity and is designed to meet their interests and promote the highest practicable level of physical, mental, and psycho-social well-being.
K 0161
Door wedge was removed and disposed of on 4/17.
The missing magnet/part, for Kitchen door, was identified and ordered on 4/28, part received on 4/29, and part installed on kitchen door on 4/29.
On Thursday, 5/1, a fire drill was initiated and confirmed the new part/magnet worked in conjunction with the facility's fire alarm system.
The Supervisor of B&G and/or designee will re-educate/in-service the B&G staff in regard to maintaining common wall doors to be free of impediments to close, including door wedges.
The Director of Dietary and/or designee will re-educate/in-service dietary staff in regard to maintaining common wall doors to be free of impediments to close, including door wedges.
The Supervisor of B&G and/or designee will perform one documented weekly visual audit of the kitchen door, for one month, then two documented visual audits per month for two months of the kitchen door to assure the kitchen door is free of impediments to close, including door wedges. After which random visual audits will be performed at least quarterly.
The results of the audits will be submitted to the QAPI Committee monthly, for three months, for review and determination of need for further action as needed.
Facility alleges substantial compliance on May 15, 2025.
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