Non-compliance with Building Construction Type Limitations
Penalty
Summary
The facility was found to be non-compliant with the 2012 NFPA 101: 19.1.6.1 regulation, which limits existing health care occupancies to specific building construction types. The building in question was identified as Type II (000) construction, which is restricted to two stories in height and requires complete automatic sprinkler protection. However, the facility was observed to have four floors, indicating a violation of the construction type limitations. This deficiency was noted during a life safety survey conducted on December 17, 2024, between 8:30 am and 11:00 am. The facility is currently working to create a rated ceiling system throughout to address this non-compliance, and a time-limited waiver is in place until October 31, 2025, to allow for the completion of the necessary repairs.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 Element 1 K 161 Corrective Action: The facility was approved for a limited-time waiver with an expiration date of (MONTH) 31, 2025. Brookstone Contractors began the current ceiling replacement with materials and assemblies that are UL-listed to provide a 2-hour rating, and this project started on (MONTH) 19, 2024. Project Status: - Lobby: All ceiling grids, tiles, and lighting have been replaced throughout the lobby, kitchen, IT Room, and all non-clinical areas. - 2 East: Dayrooms/Common area grids, ceiling tiles, and lighting have been completed. - 3 West: Dayroom/Common area grids, ceiling tiles, and lighting have been completed. - 3 East: Dayroom Common area grids, ceiling tiles, and lighting have been replaced. Work to begin on (MONTH) 11, 2025, in the following resident rooms: E 300, 302, 303, 304, 305, 306, 308, 309, 311, 315, 317, 318, 339. - 4 East: Completed. - 4 West: Dayroom Common area grids, ceiling areas, and lighting have been completed. Work on the following resident rooms has been completed: 400, 402, 404, 406, 408, 410. Element 2: All residents have the potential to be affected by this practice. Element 3: The maintenance director oversees the project to ensure Interim Life Safety plan compliance. Staff members responsible for facility maintenance are trained on the periodic inspection of fire-rated ceiling systems. The facility will communicate quarterly updates to the Department of Health. Element 4: Monitoring: The maintenance director will audit weekly measures such as fire watch during construction, increased fire drills, and staff training at the facility. The results of this audit will be reported to the administrator monthly. The maintenance director will submit quarterly reports to the QAPI Committee for 3 quarters. The QAPI Committee will determine if any further action is required. Element 5: Person Responsible: Director of Maintenance.