Deficiency in Corridor Wall Construction
Penalty
Summary
During a Life Safety Code recertification survey, it was observed that the facility did not ensure that corridor walls were constructed in accordance with NFPA 101 standards. Specifically, a door assembly in the corridor wall failed to form a barrier to limit the transfer of smoke. This deficiency was noted on one of the six floors, specifically in the Electrical Closet on the Lobby Floor. An opening measuring approximately 3 inches by 4 inches was found in the corridor wall just above the corner of the door frame. This opening was covered by wallpaper on the corridor side and held down with a screw. The Director of Maintenance acknowledged that the opening occurred when the new door assembly was installed, and the Administrator confirmed that the door and door frame had been installed about a year prior.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The maintenance staff permanently sealed the opening in the identified corridor wall above the Electrical Closet door on the Lobby Floor on 2/7/2025. The corridor wall resists the passage of smoke. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility acknowledges that all residents have the potential to be affected by this practice. The Director of Maintenance inspected all areas throughout the facility for same deficiencies. No negative outcome. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: All maintenance staff will receive additional education, and all participants will understand the life safety issues identified, with the proper construction of corridor walls in compliance with 2012 NFPA 101 19.3.6.2. An audit tool was developed to inspect the corridor walls for penetration. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a weekly basis, for one quarter, the Dir. Maintenance or designee will audit all corridor walls for penetration to ensure compliance. Any outstanding issues will be addressed immediately and reported to the Administrator. On a monthly basis, The Director of Maintenance or Designee will review monthly audits and report findings to Administrator. On a quarterly basis, The Director of Maintenance or Designee will report the result of the audits to the QAPI. 5. The title of the person responsible for correction of each deficiency: Administrator, Director of Maintenance.