Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on May 21, 2021, 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 26, 2021, 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 construction, which is fully sprinklered.
State Plans approved as Prompt.
Plan of Correction:
Initial Comments:
Name - SLOW (ORANGE COTTAGE) Component - 02
Facility ID# 04811100
Component 02
Orange Cottage
Based on a Medicaid Recertification Survey completed on May 26, 2021, 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 construction, which is fully sprinklered.
State Plans approved as Slow.
Plan of Correction:
Initial Comments:
Name - SLOW (BLUE COTTAGE) Component - 03
Facility ID #04811100
Component 03
Blue Cottage
Based on a Medicaid Recertification Survey completed on May 26, 2021, 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 construction, which is fully sprinklered.
State Plans approved as Slow.
Plan of Correction:
Initial Comments:
Name - PROMPT (GREEN COTTAGE) Component - 04
Facility ID# 04811100
Component 04
Green Building
Based on a Medicaid Recertification Survey completed on May 26, 2021, 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 construction, which 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 26, 2021, it was determined 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 construction, which is fully sprinklered.
State Plans approved as Impractical.
Plan of Correction:
NFPA 101 STANDARD
Corridor - Doors
Name - IMPRACTICAL (PURPLE COTTAGE) Component - 05
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 maintain the unobstructed closing of corridor doors, affecting the entire component.
Findings include:
1. Observation on May 26, 2021, at 11:44 a.m., revealed the door to Apartment 12, Bedroom 2, was obstructed from closing by a transition strip within the flooring.
Exit Interview with the Director of Facilities on May 26, 2021, at 11:44 a.m., confirmed the obstructed corridor door.
Plan of Correction:On May 26, 2021, the threshold was repaired and fastened to the floor with new screws. This provided an immediate correction to the problem.
Going forward, a monthly visual inspection by the Maintenance department will be conducted to verify all doors close with no obstruction.
Target Date: May 26, 2021
Initial Comments:
Name - SLOW (RED COTTAGE) Component - 06
Facility ID #04811100
Component 06
Red Building
Based on a Medicaid Recertification Survey completed on May 26, 2021, 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 construction, which is fully sprinklered.
State Plans approved as Prompt.
Plan of Correction:
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