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 01 - Component: 01 - Tag: 0161
Based on document review and interview, the facility failed to maintain the building construction type, potentially affecting the structural integrity of one of one building.
Findings include:
Document review on January 10, 2024, at 10:05 a.m., revealed the facility failed to follow up on a building structural assessment quote provided by a vendor on July 19, 2023. The quote was obtained as part of the plan of correction from an initial survey completed on June 21, 2023. The facility provided the quote on the day of the revisit survey conducted on August 2, 2023. However, through interview on January 10, 2024, at 10:11 a.m., no additional action was performed to analyze, evaluate, or repair the items outlined in K-161 from the June 21 onsite survey.
Interview with the administrator on January 10, 2024, at 10:05 a.m., confirmed the facility did not follow-up on the building structural assessment quote.
Based on observation and interview, the facility failed to inspect and maintain fire-rated ceiling tiles, as part of the two-hour fire separation between floors, on three of six levels.
Findings include:
Observation on January 10, 2024, between 9:53 a.m. and 10:54 a.m., revealed the following locations had damaged or missing fire-rated ceiling tiles:
A. (9:53 a.m.) Third floor, resident room 305, had a missing fire-rated ceiling tile;
B. (10:26 a.m.) First floor, doctor office, had a missing fire-rated ceiling tile;
C. (10:54 a.m.) Basement, maintenance director office, had a missing fire-rated ceiling tile.
Interview with the maintenance technician on January 10, 2024, at 10:54 a.m., confirmed the deficiencies.
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Based on document review and interview during an Onsite Revisit Survey conducted on March 4, 2024, it was determined the facility failed to provide a full, detailed report from a follow-up visit by the structural engineering consultant.
Documents provided revealed that the engineering group conducted an assessment in December 2023 following the building structural assessment quote received July 19, 2023. The administrator stated that multiple attempts were made to obtain the report following the assessment. On the day of the Revisit Survey, the facility contacted the engineering consultant group to obtain the full report. However, the group provided a portion, identified as "Attachment A". The attachment contains forty pages of photographs showing the location and a brief description of the area. The attachment did not mention if the facility needed to take additional action for pending corrections.
Due to the report delay, the facility is in contact with an alternative consulting organization. An email (dated March 4, 2024) was provided that detailed an agreement for life safety consultant services with this company, with the company having reviewed the facility, spoken to staff regarding the structural evaluation, and planning to be on-site to continue evaluating the building to formulate a plan in the future. No additional documents from this company were reviewed at the time of the survey.
Interview with the administrator on March 4, 2024, at 12:15 p.m., confirmed the facility failed to provide documentation for additional action from the engineering assessment.
| | Plan of Correction - To be completed: 04/02/2024
As discussed in the 2567, the facility is in contact with an alternative consulting organization. This company has presented a phased approach of repairs regarding the structural issues. This work will begin on March 29, 2024.
The engineering assessment report was reviewed with the life safety consultant. It was recommended that a phased approach to items on the engineering assessment report follow those of immediate repairs that relate to routine maintenance, overall safety and building structure, followed by a strategic plan, obtaining written estimates and securing permits if applicable, as well if necessary, gathering the labor and resources required for the work. In addition, the engineering report and phased approach will be available for the life safety surveyor during the revisit.
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