Inaccurate Life Safety Code Floor Plans and Missing Safety Features
Penalty
Summary
The facility was found to be deficient in providing an accurate and portable set of floor plans during a document review conducted on April 8, 2025. The Division of Safety Inspection mandates that all facilities under its jurisdiction maintain such floor plans on-site for use during Life Safety Code Surveys. The review revealed that the facility's floor plans were not accurate, as confirmed by the maintenance director. This deficiency was noted during an interview with the maintenance director, who acknowledged the inaccuracy of the Life Safety Code Floor Plan at the time of the survey. Additionally, an observation conducted on the same day revealed multiple areas within the facility that lacked doors and smoke detection systems leading to the corridor. Furthermore, the facility was unable to provide accurate rating information for the dining room doors leading to the entertainment area. The Life Safety Code Floor Plan is required to include specific details such as smoke barrier walls, fire barrier walls, horizontal exits, rated rooms, required exits, shaft walls, and a door schedule. The absence of these elements in the facility's floor plan contributed to the deficiency noted in the survey.
Plan Of Correction
Maintenance Director and Administrator will update the floor plan with clear description of: a. smoke barrier walls (outside wall to outside wall) b. fire barrier walls (1-2 hour walls) c. horizontal exits d. rated rooms (storage rooms, soiled utility rooms, designated medical gas rooms) e. exits noted f. shaft walls g. door schedule This will be completed by 5/13/2025. Maintenance Director and Administrator will update the portable floor plan to keep in life safety manual to include: a. smoke barrier walls (outside wall to outside wall) b. fire barrier walls (1-2 hour walls) c. horizontal exits d. rated rooms (storage rooms, soiled utility rooms, designated medical gas rooms) and they will be clearly designated e. required exits clearly noted f. shaft walls g. door schedule This will be completed by 5/14/2025.