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 the rated horizontal fire doors to close and latch within the frame, in two of six smoke compartments within the component. Findings include: 1. Observation on January 16, 2024, between 1:30 PM and 2:32 PM, revealed multiple horizontal fire-rated access doors failed to self-close and latch in the frame, at the following locations: a. 1:30 PM, 1st floor, Dining Storage Closet; b. 2:32 PM, 1st floor, Laundry Room.
Interview at the time of the exit conference with the Administrator, Director of Facilities, and Building and Grounds Supervisor on January 16, 2024, at 2:45 PM confirmed the horizontal fire-rated access doors would not self-close and latch.
| | Plan of Correction - To be completed: 03/13/2024
The mentioned horizontal access fire doors will be replaced. Replacement and installation will be completed upon receipt of doors, but no later than 14 days after receipt.
Facilities Director or designee will complete a monthly audit for 3 months, then quarterly x1 year audit of all horizontal access doors ensuring self-closure and positive latch within the frame.
NHA or designee will review the audit log monthly to ensure no concerns with door closure and latching for three months, then quarterly x 1 year. Findings will be reviewed at QAPI for further evaluation and recommendations.
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