Failure to Maintain Fire Resistance Rating in Common Walls
Penalty
Summary
The facility failed to maintain the fire resistance rating of common walls, which is a requirement for sections of health care facilities classified as other occupancies. During an observation, it was noted that there was an unsealed penetration around data wires above the common wall doors separating Willowbrooke Court and the Independent Living Unit. This deficiency was identified on one of the two levels of the facility. The issue was confirmed during an exit interview with the Administrator and Maintenance Director.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of State and Federal Law. The plan of corrections represents the community's credible allegation of compliance. Maintenance technician sealed the identified penetrations around the data wires above the common wall doors separating Willowbrooke Court and Independent Living Unit using UL system WL-3423 on 1/29/2025. The Maintenance Department will be in-serviced by 2/14/2025 the Director of Property Management/ Designee on maintaining the fire resistance rating of common walls. All fire door separations in Willowbrooke Court were audited by 2/12/2025 by maintenance technician for penetrations and maintenance of fire rating. The Director of Property Management or designee will conduct random weekly audits x4 weeks to check fire resistance rating of common walls, affecting one of two levels. All findings will be reported to QAPI Committee.