Unsealed Wall Penetration Compromises Fire Barrier
Penalty
Summary
During a facility tour and interview with the Maintenance Director, surveyors observed a deficiency related to the building's construction. Specifically, in Room 203, there was a drain cap underneath the restroom sink that was not flush with the wall, resulting in an approximately seven-inch crescent-shaped penetration. This opening was identified as a potential pathway for smoke and gases to travel between different parts of the building, which is not in compliance with fire safety requirements for health care occupancies. The Maintenance Director was interviewed at the time of the observation and stated that he was unsure how long the penetration had been present. This deficiency affected 32 out of 192 residents in one of the six smoke compartments within the facility. The report does not provide additional details about the specific medical history or condition of the residents affected at the time of the deficiency.
Plan Of Correction
The following Plan of Correction is submitted by the facility in accordance with the pertinent terms and provisions of 42 CFR Section 488 and/or related state regulations and is intended to serve as a credible allegation of our intent to correct the practices identified as deficient. The Plan of correction should not be construed or interpreted as an admission that the deficiencies alleged did, in fact, exist; rather, the facility is submitting this document in order to comply with its obligations as a provider participating in Medicare/Medicaid program(s). K161 NFPA 101 Building Construction type and height. How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: The Penetration in Room 203 was immediately fixed. No residents were affected by this finding. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken. All residents have the potential to have been affected by the practice. Maintenance director and assistant checked all other drain caps in all restrooms and no issues were identified. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur. Maintenance Staff were in serviced on June 2, 2025 by administrator regarding the policy penetrations in the facility. Maintenance Director or designee will check all storage rooms and hallways to ensure there are no penetrations weekly for the next 3 months. Dept heads or designee will check their Guardian Angel rooms weekly for any penetrations for the next 3 months. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The Administrator or designee will do rounds weekly for the next 3 months to monitor for compliance. Any issues will be reported to the Quality Assurance committee for review and recommendations. Completion date of corrective actions: June 9, 2025. K 161