K0636

E

Corridor Smoke Protection Deficiency

Premier Nsg & Rehab Center Of Far RockawayFar Rockaway, New York Survey Completed on 03-07-2025

Summary

The facility failed to ensure that all corridors were protected from the passage of smoke, as required by the 2012 NFPA 101 standards. During a life safety survey, it was observed that alcoves used to store combustible items, such as linens, were open to the corridor on all floors, including the basement. This configuration could allow smoke to pass into the corridor in the event of a fire. These findings were confirmed through observation and staff interviews, specifically with the Director of Maintenance.

Plan Of Correction

Plan of Correction: Approved March 19, 2025 K636 P(NAME)

I. Immediate Corrections:
a. Director of Environmental Services checked all alcoves where linens are stored on resident floors and noted half door partitions.
b. Director of Environmental Services took measurements and will be installing full doors to ensure all corridors were protected from passage of smoke.

II. Identification:
a. The facility respectfully acknowledges this deficiency affects all residents.

III. Systemic Changes:
a. Administrator and Director of Environmental Services reviewed Fire Safety Policy. No Updates Necessary.
b. Director of Environmental Services in-serviced all maintenance staff on protecting corridor from smoke in case of fire.

IV. Monitoring:
a. Director of Environmental Services developed an audit tool for alcoves to ensure proper closure and from passage of smoke.
b. Audits will be done quarterly for one year.
c. All negative findings will be immediately addressed.
d. All audit findings will be presented to the QA committee quarterly by the Director of Environmental Services / designee.

V. Responsibility:
a. The Director of Environmental Services will be responsible to ensure correction of this deficiency.

Penalty

No penalty information released