Building Rehabilitation
Repair, Renovation, Modification, or Reconstruction
Any building undergoing repair, renovation, modification, or reconstruction complies with both of the following:
* Requirements of Chapter 18 and 19
* Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6
18.1.1.4.3, 19.1.1.4.3, 43.1.2.1
Change of Use or Change of Occupancy
Any building undergoing change of use or change of occupancy classification complies with the requirements of Section 43.7, unless permitted by 18.1.1.4.2 or 19.1.1.4.2
18.1.1.4.2 (4.6.7 and 4.6.11), 19.1.1.4.2 (4.6.7 and 4.6.11), 43.1.2.2 (43.7)
Additions
Any building undergoing an addition shall comply with the requirements of Section 43.8. If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a 2-hour fire resistance rating constructed of materials as required for the addition.
Communicating openings occur only in corridors and are protected by approved self-closing fire doors with at least a 1-1/2-hour fire resistance rating. Additions comply with the requirements of Section 43.8.
18.1.1.4.1 (4.6.7 and 4.6.11), 18.1.1.4.1.1 (8.3), 18.1.1.4.1.2, 18.1.1.4.1.3, 19.1.1.4.1 (4.6.7 and 4.6.11), 19.1.1.4.1.1 (8.3), 19.1.1.4.1.2, 19.1.1.4.1.3, 43.1.2.3(43.8)
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Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0111
Based on observation and interview, it was determined the facility failed to complete repairs before state of unrepair had a major impact on the building, affecting one of 14 smoke compartments within the component.
Findings include:
1.Observation on September 25, 2025, at 11:15 AM, revealed a ceiling tile in the corridor of the Personal Care Wing, 2nd floor, had fallen, due to water damage. Additionally, there was a drainage hose set up, in the Living Room, to prevent damage in that area.
Interview with the Maintenance Manager and the Nursing Home Administrator on September 25, 2025 at 11:15 AM, confirmed the ceiling damage and on-going mitigation for a roof leak.
| | Plan of Correction - To be completed: 10/20/2025
1. The ceiling tile in the corridor of the Personal Care Wing, 2nd floor, which had fallen due to water damage was repaired and the drainage hose set up, in the Living Room, was removed on 9/29/25.
2. The remaining ceiling tiles in the Personal Care Wing were audited initially to ensure no further water damage and a roof examination and repairs were completed by Capital Coating on 9/29/29 to prevent future water damage to ceiling tiles.
3. Maintenance Director was reeducated by NHA to ensure ceiling tiles remain free from water damage.
4. Ceiling tiles will be audited 1 time a week in the facility for water damage weekly for 4 weeks and the monthly for 3 months by Maintenance Director or designee. Results will be reviewed in QAPI.
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