Unsealed Wall Penetration Compromises Fire Barrier
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
Penalty
Surveyors found that the facility, classified as a five-story Type II (000) unprotected non-combustible building with a basement, exceeded the maximum allowable number of stories for its construction type, despite being fully sprinklered. This non-compliance with NFPA 101 fire resistance requirements was confirmed by facility leadership and affects the entire building.
The facility did not follow up on a vendor-provided building structural assessment quote that was part of an ongoing plan of correction, as confirmed by document review and interview with the maintenance supervisor. This failure potentially affected the building's structural integrity.
Surveyors found that the facility did not maintain the required fire resistive rating on one floor, as missing rated ceiling tiles were observed in the second floor IT/Conference Room and confirmed by the Administrator and Maintenance Director.
Surveyors found that the facility is a four-story, Type II (000) unprotected noncombustible structure that is fully sprinklered, which exceeds the maximum number of stories allowed by the 2012 Life Safety Code for this construction type. Facility leadership confirmed the building's structure does not meet code requirements.
A survey found that the facility is a three-story, Type II (000) unprotected noncombustible building with a basement, which exceeds the maximum allowable story height for this construction type. The Director of Maintenance confirmed that the building's construction type and height are not permitted under current regulations.
During a facility inspection, an unsealed four-inch penetration was found in the ceiling of the electrical room, with a conduit passing through. The Maintenance Consultant stated that this resulted from recent utility upgrades where the vendor did not seal the opening after completing their work. The deficiency affected one of two smoke compartments.
Non-Compliance with Fire Resistance Rating Due to Excessive Building Height
Penalty
Summary
Surveyors determined that the facility failed to maintain compliance with the fire resistance rating requirements for building construction as outlined in NFPA 101. During document review and observation, it was found that the facility is a five-story building with a basement, classified as Type II (000) unprotected non-combustible construction, and is fully sprinklered. According to the applicable code, this construction type is not permitted to exceed one story, even if sprinklered, but the facility exceeds this limit by three stories. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Directors, who acknowledged that the building's story height does not meet the maximum allowance for its construction type. The deficiency affects the entire facility, as the building's structure does not align with the required fire safety standards for its classification.
Plan Of Correction
On CMS guidance, a Time Limited Waiver will be initiated related to this deficient practice. Subsequently, CMS changed the FSES calculation, relieving health care occupancies of the NFPA standard requiring fire-protective coating for structural steel supports in buildings of five stories or more. A life safety consultant will be contracted to perform an updated FSES related to this deficient practice.
Failure to Follow Up on Building Structural Assessment
Penalty
Summary
The facility failed to maintain compliance with NFPA 101 requirements regarding building construction type and height. Specifically, the facility did not follow up on a building structural assessment quote that was provided by a vendor as part of an ongoing plan of correction. This quote was initially obtained in response to a previous survey, but no further action was taken to address the structural assessment needs. During document review and an interview with the maintenance supervisor, it was confirmed that the facility did not proceed with the necessary follow-up on the structural assessment. This inaction potentially affected the structural integrity of the building, as the required evaluation and any subsequent actions were not completed.
Plan Of Correction
The building structural assessment quote from February 27, 2025, will be reviewed with the Regional team and vendor for availability for service completion. The Director of Maintenance will follow up once a date is confirmed that the work will be completed. The Director of Maintenance will report to the monthly Quality Assurance meeting on the progress of the work.
Failure to Maintain Fire Resistive Rating Due to Missing Ceiling Tiles
Penalty
Summary
Surveyors determined that the facility failed to maintain the required fire resistive rating of the building construction, specifically affecting one of two floors. During an observation, missing rated ceiling tiles were identified in the second floor IT/Conference Room. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director, who acknowledged the absence of the required ceiling tiles. No information regarding residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
Maintenance director replaced missing rated ceiling tiles in the first floor mechanical room on 8/18/2025. The Maintenance Director will conduct a facility-wide audit for any missing rated ceiling tiles and replace tiles as indicated. Maintenance director to be reeducated on policy K0161 by the NHA or Designee. Compliance will be monitored by the Maintenance Director/Designee through 5 random audits weekly x 4 for any ceiling tiles that need to be replaced. Audit results to be reviewed at the QA Committee to determine the need for further follow-up/monitoring.
Noncompliance with Building Construction Type and Height Requirements
Penalty
Summary
Surveyors determined that the facility failed to comply with building construction requirements as outlined in the 2012 Edition of the Life Safety Code. During a document review and on-site observation, it was found that the facility is a four-story, Type II (000) unprotected noncombustible structure that is fully sprinklered. According to the Life Safety Code, this type of construction is not permitted to exceed two stories for an existing sprinklered health care occupancy. The deficiency was confirmed during an exit conference with facility leadership, including the Administrator, Regional Director, Regional Maintenance Director, and Environmental Services Director. The facility's documentation and physical structure did not meet the required standards for the number of stories allowed for its construction type, as specified by the applicable code.
Plan Of Correction
Facility is requesting DOH complete an FSES for us. Center will submit life safety drawings that were requested.
Noncompliance with Building Construction Type and Height Requirements
Penalty
Summary
The facility failed to maintain compliance with building construction requirements as specified by NFPA 101. During an observation, it was found that the building is a three-story, Type II (000) unprotected noncombustible structure with a basement, which exceeds the maximum allowable story height for this construction type. The deficiency was confirmed through an interview with the Director of Maintenance, who acknowledged that the construction type and height do not meet the permitted standards. No information about specific residents or their conditions was provided in the report. The deficiency centers on the facility's noncompliance with the required building construction type and height limitations, as the structure's number of stories surpasses what is allowed for its construction classification.
Unsealed Ceiling Penetration in Electrical Room
Penalty
Summary
A deficiency was identified during a facility tour and interview with the Maintenance Consultant, where an unsealed penetration was observed in the ceiling of the electrical room. The penetration, approximately four inches in size, was located on the south side of the electrical room ceiling, with a conduit passing through the space. This condition was noted during an inspection and was directly observed by the surveyor. The Maintenance Consultant explained that the facility had recently undergone utility upgrades, and the vendor responsible for the work failed to seal the penetration after completing the project. This unsealed opening was present in one of two smoke compartments within the building. No information was provided regarding any residents or their medical conditions in relation to this deficiency.
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