Multiple Occupancies - Construction Type Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, 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 18/19.1.6.1 * The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters. 18.1.3.5, 19.1.3.5, 8.2.1.3
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Observations: Name: MAIN BUILDING - Component: 01 - Tag: 0133
Based on observation and interview, it was determined the facility failed to maintain the 2-hour fire resistance rating of communicating openings, on one of four smoke compartments within the component.
Findings include:
1. Observation on February 13, 2024, at 2:00 PM, revealed the double corridor fire-rated doors, separating Personal Care from Nursing Care, had gaps, greater than 3/16 inch.
Interview with the Director of Facilities on February 13, 2024, at 2:00 PM, confirmed the gaps, greater than 3/16 inch.
| | Plan of Correction - To be completed: 04/12/2024
The door separating Nursing Care and Personal Care on the 1st floor by the physical therapy gym was noted with a gap over the allowable measurement, was evaluated by door vendor for replacement on February 19, 2024. Rated door in corridor separating Nursing Care from Personal care, the door separating the Nursing care protected passageway by the therapy gym was evaluated by door vendor for replacement on February 19, 2024. Further action to be taken to request a time-limited waiver to ensure that replacement of the door is completed in an appropriate timeframe. A memo was issued to all Department Directors on February 28, 2024, to ensure that warped, malfunctioning or gap penetrated doors are reported to the maintenance department for repair/replacement immediately upon finding. The Maintenance Department will perform random audits of facility compliance with door operation and quality monthly until a compliance threshold is met for three consecutive months. Unfavorable results will be reported to the Performance Improvement Committee upon completion. Time limited waiver request submitted to allow for additional time to install the new doors by July 15, 2024.
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