Non-Compliance with Building Construction Type Requirements
Penalty
Summary
The facility was found to be non-compliant with building construction type requirements during a survey conducted on April 8, 2025. The first deficiency was observed when the fire door separating component 01 from component 02, located next to the resident entertainment room, failed to positively close or latch when released. This issue was confirmed during an interview with the maintenance director, who acknowledged the door's failure to latch at the time of inspection. Additionally, a document review revealed that the facility lacked documentation proving that the discharge exit canopy near room 112 was flame retardant. The canopy, which extends over four feet from the building and is attached to it, does not have sprinkler coverage, necessitating it to be inherently flame retardant. The maintenance director confirmed the absence of flame retardant documentation during the survey.
Plan Of Correction
Maintenance Director has replaced the latch on the fire door separating component 01 from component 02, located next to the resident entertainment room on 4/12/2025. The door now properly latches when released. The Maintenance Director will audit twice a week, Monday through Friday - ongoing. The results of the audit will be reviewed in the quality assurance committee monthly to determine if a quality assurance plan is required.