Deficiency in Corridor Wall Construction
Summary
The facility failed to ensure that the corridor walls were constructed to resist the passage of smoke as required by NFPA 101: 2012 Edition, Section 19.3.6.2 and 19.3.2.7. This deficiency was identified during an observation on December 4, 2024, at 9:41 AM, when a hole was found in the wall above the laundry corridor door in the ceiling of the East Wing. This observation was confirmed by a staff member present at the time. The issue was communicated to the facility's representative during the Life Safety Code exit conference on December 5, 2024, at 2:45 PM.
Plan Of Correction
Completion Date: 12-25-2024 Facility ID: 3145384 Survey completion date: 12-12-2024 K362 - E Corridors - Construction of Walls Element One: The hole in the wall above the laundry corridor door in the ceiling was immediately sealed. Element Two: This deficient practice had the potential to affect all East Wing residents. Element Three: The U.S. FOIA (b) (6) was educated on the requirements related to ensuring the corridor walls are constructed to resist the passage of smoke. Element Four: The Maintenance director / designee will audit the above findings monthly x3 to ensure the hole remains sealed and passage of smoke is resisted. Results will be reported to the QAPI team for review.
Penalty
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