Unsealed Smoke Barriers and Missing Smoke Damper Documentation
Penalty
Summary
The facility failed to ensure that penetrations in smoke barriers were adequately sealed, which is a requirement under the NFPA 101 Life Safety Code (2012 Edition). During an observation, a 1-inch unsealed hole with blue wires extending through it was found in the smoke barrier inside Room 320, as well as in Rooms 220 and 218. This deficiency was confirmed by a staff member during the observation, who stated that the facility was unaware of these unsealed gaps and penetrations. Additionally, the facility lacked documented evidence of a four-year testing or maintenance of its smoke dampers, as required. During an interview, a staff member was not aware of the missing documentation, indicating a lapse in the facility's maintenance and documentation processes.
Plan Of Correction
1. Corrective Action of Areas Affected: The penetrations in rooms 218, 220 and 320 have been sealed. The required 4 year testing on the smoke dampers has been completed. 2. Other Areas Affected: All residents have the potential to be affected by this deficient practice. The Director of Maintenance/Designee has conducted an inspection in 100% of all resident rooms for additional penetrations and any additional ones found have been sealed. 3. Systemic Changes to Prevent Future Occurrences: Inspection for penetrations in smoke barriers has been placed on a monthly preventative maintenance inspection by the Director of Maintenance/Designee. The Maintenance Director will submit this monthly inspection to the Administrator. 4. Monitoring of Corrective Action: The Director of Maintenance will submit a report monthly to the Administrator who will forward it x 3 months to the monthly Quality Assurance Improvement Meetings for review and recommendations.