Wall Penetration Compromises Fire Barrier Integrity
Penalty
Summary
A deficiency was identified when a penetration, approximately an inch and a half in diameter, was observed on the east wall by the main entrance to the kitchen, about 18 inches from the ceiling. This breach in the wall's integrity was noted during a facility tour and interview with staff. The penetration could potentially compromise the building's construction standards as required by 42 CFR §483.90 and NFPA 101, specifically regarding the containment of smoke in the event of a fire. The deficiency affected 27 of 92 residents and one of six smoke compartments. No information was provided about the medical history or condition of the residents involved at the time of the deficiency.
Plan Of Correction
Date of Compliance 4/18/25 Tag K 161: Building Construction Type and Height How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The EVS Director fixed the identified penetration on 4/9/25. Maintenance staff have been retrained on monitoring and promptly repairing any penetrations in fire-rated walls. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: No additional residents have the potential to be affected. This penetration affected one smoke compartment which contains no resident space. A facility-wide inspection was conducted to identify and seal any additional penetrations in fire-rated walls. No other unsealed penetrations were found. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: A quarterly wall inspection program has been implemented. Maintenance staff were trained on 4/9/25 by the administrator on fire-rated wall requirements and the importance of preserving wall integrity. Any new penetrations discovered will be fixed immediately. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the