Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on May 5, 2025, at Communities Of Don Guanella And At Divine Providence Village, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.475.
Plan of Correction:
Initial Comments:
Name - PROMPT (YELLOW COTTAGE) NOW SLOW 4/25/2013 Component - 01
Facility ID# 04811100
Component 01
Yellow Cottage
Based on a Medicaid Recertification Survey completed on May 5, 2025, it was determined that Communities Of Don Guanella And At Divine Providence Village was not in compliance with the following requirements of the Life Safety Code for an existing ICF/IID health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.470(j).
This is a one-story, Type III (211), protected ordinary building, that is fully sprinklered.
State Plans approved as Prompt.
Plan of Correction:
NFPA 101 STANDARD
Means of Egress - General
Name - PROMPT (YELLOW COTTAGE) NOW SLOW 4/25/2013 Component - 01
Means of Escape - General
2012 EXISTING
Designated means of escape shall be continuously maintained clear of obstructions and impediments to full instant use in the case of fire or emergency.
33.2.2
Observations:
Based on observation and interview, it was determined the facility failed to maintain means of egress free from all obstructions, affecting one of two smoke compartments in the component.
Findings include:
Observation on May 5, 2025, at 9:57 a.m., revealed the left side exit door required excessive force to open.
Exit interview with the Maintenance Director on May 5, 2025, at 10:15 a.m., confirmed the required excessive force.
Plan of Correction:The left side exit door needed excessive force to open the door.
The weather stripping was causing the door to not open properly. The maintenance team repaired the weather stripping on 5-5-25 and the door is working properly now. All exit doors will be checked during monthly maintenance walk throughs.
NFPA 101 STANDARD
Hazardous Areas - Enclosure
Name - PROMPT (YELLOW COTTAGE) NOW SLOW 4/25/2013 Component - 01
Hazardous Areas - Enclosure
2012 EXISTING (Prompt)
Any hazardous area that is on the same floor as, and is in or abut, a primary means of escape or a sleeping room shall be protected by one of the following means:
1. Protection shall be an enclosure with a fire resistance rating of not less than 1 hour, with a self-closing or automatic closing fire door in accordance with 7.2.1.8 that has a fire protection rating of not less than 3/4 hour.
2. Protection shall be automatic sprinkler protection, in accordance with 33.2.3.5, and a smoke partition, in accordance with 8.4 located between the hazardous area and the sleeping area or primary escape route. Any doors in such separation shall be self-closing or automatic closing in accordance with 7.2.1.8.
Other hazardous areas shall be protected in accordance with 33.2.3.2.5 by one of the following:
1. An enclosure having a fire resistance rating of not less than 1/2 hour, with a self-closing or automatic-closing door in accordance with 7.2.1.8 that is equivalent to not less than a 13/4 inch (4.4 cm) thick, solid-bonded wood core construction.
2. Automatic sprinkler protection in accordance with 33.2.3.5, regardless of enclosure.
Areas with approved, properly installed and maintained furnaces and heating equipment, and cooking and laundry facilities are not classified as hazardous areas solely on basis of such equipment.
Standard response sprinklers shall be permitted for use in hazardous areas in accordance with 33.2.3.2.
33.2.2.2.4, 33.2.3.2, 33.2.3.2.5
Observations:
Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of hazardous areas, affecting one of two smoke compartments in the component.
Findings include:
Observation on May 5, 2025, at 9:58 a.m., revealed the Linen Closet on the left side next to the Exit Door lacked a self-closer.
Exit interview with the Maintenance Director on May 5, 2025, at 10:15 a.m., confirmed the lack of self-closer.
Plan of Correction:The storage closet on the left side of the building did not have a self-closer on the door.
The maintenance team will be installing a door closer to the storage closet. All storage closets will be checked monthly to ensure there is a self-closer on the door.
NFPA 101 STANDARD
Corridor - Doors
Name - PROMPT (YELLOW COTTAGE) NOW SLOW 4/25/2013 Component - 01
Corridor - Doors
Doors shall meet all of the following requirements:
1. Doors shall be provided with latches or other mechanisms suitable for keeping the door closed.
2. No doors shall be arranged to prevent the occupant from closing the door.
3. Doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 in buildings other than those protected throughout by an approved automatic sprinkler system in accordance with 33.2.3.5.
Door assemblies with leaves required to swing in the direction of egress travel are inspected and tested annually per 7.2.1.15.
33.2.3.6.4, 33.7.7
Observations:
Based on observation and interview, it was determined the facility failed to ensure corridor doors latched in their frames, affecting one of two smoke compartments in the component.
Findings include:
Observation on May 5, 2025, at 9:56 a.m., revealed the resident room across from the Shower Room failed to close and latch.
Exit interview with the Maintenance Director on May 5, 2025, at 10:15 a.m., confirmed the door failed to close and latch.
Plan of Correction:The resident room across from the shower room failed to close and latch.
The rubber transition that was causing the door not to latch has been changed so the door will latch properly. The maintenance team checks the doors on a monthly schedule.
Initial Comments:
Name - SLOW (ORANGE COTTAGE) Component - 02
Facility ID# 04811100
Component 02
Orange Cottage
Based on a Medicaid Recertification Survey completed on May 5, 2025, it was determined that Communities Of Don Guanella And At Divine Providence Village was not in compliance with the following requirements of the Life Safety Code for an existing ICF/IID health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.470(j).
This is a one-story, Type III (211), protected ordinary building, that is fully sprinklered.
State Plans approved as Slow.
Plan of Correction:
NFPA 101 STANDARD
Hazardous Areas - Enclosure
Name - SLOW (ORANGE COTTAGE) Component - 02
Hazardous Areas - Enclosure
2012 EXISTING (Prompt)
Any hazardous area that is on the same floor as, and is in or abut, a primary means of escape or a sleeping room shall be protected by one of the following means:
1. Protection shall be an enclosure with a fire resistance rating of not less than 1 hour, with a self-closing or automatic closing fire door in accordance with 7.2.1.8 that has a fire protection rating of not less than 3/4 hour.
2. Protection shall be automatic sprinkler protection, in accordance with 33.2.3.5, and a smoke partition, in accordance with 8.4 located between the hazardous area and the sleeping area or primary escape route. Any doors in such separation shall be self-closing or automatic closing in accordance with 7.2.1.8.
Other hazardous areas shall be protected in accordance with 33.2.3.2.5 by one of the following:
1. An enclosure having a fire resistance rating of not less than 1/2 hour, with a self-closing or automatic-closing door in accordance with 7.2.1.8 that is equivalent to not less than a 13/4 inch (4.4 cm) thick, solid-bonded wood core construction.
2. Automatic sprinkler protection in accordance with 33.2.3.5, regardless of enclosure.
Areas with approved, properly installed and maintained furnaces and heating equipment, and cooking and laundry facilities are not classified as hazardous areas solely on basis of such equipment.
Standard response sprinklers shall be permitted for use in hazardous areas in accordance with 33.2.3.2.
33.2.2.2.4, 33.2.3.2, 33.2.3.2.5
Observations:
Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of hazardous enclosures, affecting one of two smoke compartments in the Component.
Findings include:
Observation on May 5, 2025, at 9:46 a.m., revealed the left side Linen Closet near the Exit Door lacked a self-closer.
Exit interview with the Maintenance Director on May 5, 2025, at 10:15 a.m., confirmed the lack of self-closer.
Plan of Correction:The storage closet on the left side of the building did not have a self-closer on the door.
The maintenance team will be installing a door closer to the storage closet. All storage closets will be checked monthly to ensure there is a self-closer on the door.
Initial Comments:
Name - SLOW (BLUE COTTAGE) Component - 03
Facility ID #04811100
Component 03
Blue Cottage
Based on a Medicaid Recertification Survey completed on May 5, 2025, it was determined that Communities Of Don Guanella And At Divine Providence Village was not in compliance with the following requirements of the Life Safety Code for an existing ICF/IID health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.470(j).
This is a one-story, Type III (211), protected ordinary building, that is fully sprinklered.
State Plans approved as Slow.
Plan of Correction:
NFPA 101 STANDARD
Hazardous Areas - Enclosure
Name - SLOW (BLUE COTTAGE) Component - 03
Hazardous Areas - Enclosure
2012 EXISTING (Prompt)
Any hazardous area that is on the same floor as, and is in or abut, a primary means of escape or a sleeping room shall be protected by one of the following means:
1. Protection shall be an enclosure with a fire resistance rating of not less than 1 hour, with a self-closing or automatic closing fire door in accordance with 7.2.1.8 that has a fire protection rating of not less than 3/4 hour.
2. Protection shall be automatic sprinkler protection, in accordance with 33.2.3.5, and a smoke partition, in accordance with 8.4 located between the hazardous area and the sleeping area or primary escape route. Any doors in such separation shall be self-closing or automatic closing in accordance with 7.2.1.8.
Other hazardous areas shall be protected in accordance with 33.2.3.2.5 by one of the following:
1. An enclosure having a fire resistance rating of not less than 1/2 hour, with a self-closing or automatic-closing door in accordance with 7.2.1.8 that is equivalent to not less than a 13/4 inch (4.4 cm) thick, solid-bonded wood core construction.
2. Automatic sprinkler protection in accordance with 33.2.3.5, regardless of enclosure.
Areas with approved, properly installed and maintained furnaces and heating equipment, and cooking and laundry facilities are not classified as hazardous areas solely on basis of such equipment.
Standard response sprinklers shall be permitted for use in hazardous areas in accordance with 33.2.3.2.
33.2.2.2.4, 33.2.3.2, 33.2.3.2.5
Observations:
Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of hazardous enclosures, affecting one of two smoke compartments in the facility.
Findings include:
Observation on May 5, 2025, at 9:37 a.m., revealed the left side Linen Closet next to the Exit Door lacked a self-closer.
Exit interview with the Maintenance Director on May 5, 2025, at 10:15 a.m., confirmed the lack of self-closer.
Plan of Correction:The storage closet on the left side of the building did not have a self-closer on the door.
The maintenance team will be installing a door closer to the storage closet. All storage closets will be checked monthly to ensure there is a self-closer on the door.
Initial Comments:
Name - PROMPT (GREEN COTTAGE) Component - 04
Facility ID# 04811100
Component 04
Green Building
Based on a Medicaid Recertification Survey completed on May 5, 2025, at Communities Of Don Guanella And At Divine Providence Village, it was determined there were no deficiencies identified under the requirements of the Life Safety Code for an existing ICF/IID health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.470(j).
This is a one-story, Type III (211), protected ordinary building, that is fully sprinklered.
State Plans approved as Prompt.
Plan of Correction:
Initial Comments:
Name - IMPRACTICAL (PURPLE COTTAGE) Component - 05
Facility ID# 04811100
Component 05
Purple Cottage
Based on a Medicaid Recertification Survey completed on May 5, 2025, it was determined that Communities Of Don Guanella And At Divine Providence Village was not in compliance with the following requirements of the Life Safety Code for an existing ICF/IID health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.470(j).
This is a one-story, Type III (211), protected ordinary building, that is fully sprinklered.
State Plans approved as Impractical.
Plan of Correction:
NFPA 101 STANDARD
Hazardous Areas - Enclosure
Name - IMPRACTICAL (PURPLE COTTAGE) Component - 05
Hazardous Areas - Enclosure
2012 EXISTING (Prompt)
Any hazardous area that is on the same floor as, and is in or abut, a primary means of escape or a sleeping room shall be protected by one of the following means:
1. Protection shall be an enclosure with a fire resistance rating of not less than 1 hour, with a self-closing or automatic closing fire door in accordance with 7.2.1.8 that has a fire protection rating of not less than 3/4 hour.
2. Protection shall be automatic sprinkler protection, in accordance with 33.2.3.5, and a smoke partition, in accordance with 8.4 located between the hazardous area and the sleeping area or primary escape route. Any doors in such separation shall be self-closing or automatic closing in accordance with 7.2.1.8.
Other hazardous areas shall be protected in accordance with 33.2.3.2.5 by one of the following:
1. An enclosure having a fire resistance rating of not less than 1/2 hour, with a self-closing or automatic-closing door in accordance with 7.2.1.8 that is equivalent to not less than a 13/4 inch (4.4 cm) thick, solid-bonded wood core construction.
2. Automatic sprinkler protection in accordance with 33.2.3.5, regardless of enclosure.
Areas with approved, properly installed and maintained furnaces and heating equipment, and cooking and laundry facilities are not classified as hazardous areas solely on basis of such equipment.
Standard response sprinklers shall be permitted for use in hazardous areas in accordance with 33.2.3.2.
33.2.2.2.4, 33.2.3.2, 33.2.3.2.5
Observations:
Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of hazardous enclosures, affecting one of two smoke compartments in the component.
Findings include:
Observation on May 5, 2025, at 9:13 a.m., revealed the left side Linen Closet next to the Exit Door lacked a self-closer.
Exit interview with the Maintenance Director on May 5, 2025, at 10:15 a.m., confirmed the lack of self-closer.
Plan of Correction:The storage closet on the left side of the building did not have a self-closer on the door.
The maintenance team will be installing a door closer to the storage closet. All storage closets will be checked monthly to ensure there is a self-closer on the door.
Initial Comments:
Name - SLOW (RED COTTAGE) Component - 06
Facility ID #04811100
Component 06
Red Building
Based on a Medicaid Recertification Survey completed on May 5, 2025, at Communities Of Don Guanella And At Divine Providence Village, it was determined there were no deficiencies identified under the requirements of the Life Safety Code for an existing ICF/IID health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.470(j).
This is a one-story, Type III (211), protected ordinary building, that is fully sprinklered.
State Plans approved as Slow.
Plan of Correction:
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