Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:
o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.
Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
19.1.3.3, 42 CFR 482.41, 42 CFR 485.623
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Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0131
Based on observation and interview, it was determined the facility failed to maintain a two-hour fire resistance rating to separate the health care occupancy from other occupancies between the nursing home and the assisted living building and the medical office building in three instances, affecting three of five smoke compartments.
Findings include:
1. Observation on February 18, 2026, revealed the following occupancy separation barrier deficiencies:
a) 9:15 a.m., The two-hour wall between skilled nursing and assisted living on the second floor was not finished to the deck;
b) 10:00 a.m., The two-hour wall between skilled nursing and assisted living on the first floor was not finished to the deck;
c) 10:30 a.m., The two hour wall between skilled nursing and the medical office building was not complete to the deck above.
Interview with the Facility Administrator and Maintenance Director on February 19, 2026, at 11:00 a.m., confirmed the walls were not complete to the decking of the floor above.
| | Plan of Correction - To be completed: 04/19/2026
Facility will ensure that affected three smoke compartments deficiencies found during the inspector corrected and repaired
The maintenance staff will repair two smoke compartments, between the skilled nursing and assisted living utilizing appropriate using a UL approved through penetration firestop system
The director of maintenance or designee will contact a qualified contractor to consult on repairs for smoke compartment between skilled nursing and medical office.
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