Failure to Maintain Fire Resistance Barrier in Ceiling Assemblies
Penalty
Summary
During a recertification survey, it was observed that the facility failed to maintain the ceiling assembly to provide at least a two-hour fire resistance barrier on all four resident floors. The survey, conducted over three days, revealed unsealed openings around electrical wires and conduits in the ceiling assemblies within the electrical closets on all nursing units. This deficiency was noted despite the facility having documentation from a ceiling tile manufacturer indicating that the ceiling was equipped with a UL listed two-hour fire resistive ceiling tile assembly. The Life Safety Director of the facility acknowledged the issue during an interview, stating that the ceiling openings around the wires and conduits would be sealed with the appropriate fire stopping material. The deficiency was identified during Life Safety inspections, which took place between 9:00 am and 2:30 pm on the specified dates. The failure to maintain the fire resistance barrier as required by the 2012 NFPA 101 and 2012 NFPA 220 standards was a significant finding during the survey.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 K 161 – Building Construction Type and Height The following plan of correction is submitted in accordance with applicable law and regulation and for continued Medicare/Medicaid certification and does not constitute an admission of fault on the part of the facility. A) Immediate Corrective Action for Resident found to be affected by the deficient practice: No residents were affected by the deficient practice. The Medical Director is in agreement that there was no additional risk to residents. The facility corrected the deficiency by sealing the openings with fire stopping material around the electrical wires and conduits of the ceiling assemblies within the electrical closets on all nursing units. 01/09/2025 B) Identification of other Residents having the potential to be affected by the deficient practice: All residents have the potential to be affected by the deficient practice. Review of incident reports revealed no issues as a direct effect of the above-mentioned deficiency. A full house audit will be completed to ensure that all ceiling assemblies are free of unsealed openings. Person responsible: Director of Maintenance/ Designee C) Systemic Changes to ensure the deficient practice will not recur: The Nurse Educator will inservice all facility maintenance staff regarding the following: - all fire rated ceiling tiles and assemblies are to be free of unsealed openings; and - unsealed openings are to be sealed with appropriate fire stopping material. Education will be verified by posttests or return demonstration to ensure education retention. D) QA – Monitor of the deficient practice: Audit tool created to inspect ceiling tiles and assemblies for unsealed openings. An audit will be completed monthly to inspect 10% of ceiling tiles and assemblies to ensure areas are free of unsealed openings. Any negative findings will be immediately corrected and presented at QAPI quarterly. Audits will be completed monthly x 6 months. The Director of Maintenance is responsible for the correction of this deficiency. Date of correction: 02/18/2025