Incomplete Smoke Barriers in Facility
Summary
The facility failed to comply with the National Fire Protection Association (NFPA) 101 standards for smoke barriers, as required for existing buildings. Specifically, the facility did not install and maintain smoke barriers to form at least two smoke compartments on every sleeping floor with a capacity of 30 or more patient beds. The smoke compartments should not exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier. During an observation on January 23, 2025, at 9:05 a.m., it was revealed that the facility had incomplete smoke barriers throughout the building. This finding was confirmed in an interview with the maintenance supervisor at the same time, who acknowledged the incomplete smoke barriers on both building levels.
Plan Of Correction
The completion of smoke barriers throughout the facility was completed February 2, 2025. The Maintenance Director was educated by the Administrator on January 24, 2025 regarding the requirement for the facility to have complete smoke barriers throughout the building. An audit will be completed monthly for 4 months by the Maintenance Director to ensure that the smoke barriers throughout the facility are complete and will be monitored by the Administrator. Results of the audit will be presented at the quarterly QAPI meeting and recommendations will be implemented.
Penalty
A required smoke barrier was not present on a resident sleeping floor with 30 or more beds, as observed and confirmed by the Administrator. This resulted in the floor lacking the necessary subdivision into at least two smoke compartments.
The facility was found to have a smoke compartment on the 1st floor that exceeded the NFPA 101 maximum size of 22,500 square feet, as observed during a survey. This deficiency was confirmed in an exit interview with the CEO and Director of Campus Services.
The facility did not provide a smoke barrier map showing complete compartmentalization by smoke barriers throughout the building, as required by code. The map lacked details of smoke barriers separating compartments from outside wall to outside wall, and this was confirmed by Facility Maintenance during record review.
The facility was found to have smoke compartments exceeding the maximum allowable size of 22,500 square feet in the 400 wing and First Floor, affecting two of four smoke compartments. This was confirmed through observation, document review, and interviews with facility staff.
The facility was found to have a smoke compartment in the C Wing that exceeded the maximum allowable area of 22,500 square feet, as per NFPA 101 standards. This deficiency was confirmed during an observation and document review, affecting one of four smoke compartments.
The facility was found to have three smoke compartments exceeding the maximum allowable size of 22,500 square feet. Smoke compartments one, two, and five were identified as non-compliant during a document review and interview. This issue was confirmed in an exit interview with the Administrator and Maintenance Director.
Lack of Required Smoke Barrier on Resident Sleeping Floor
Penalty
Summary
The facility failed to provide at least two smoke compartments on each resident sleeping floor containing 30 or more resident beds, as required by NFPA 101. During an observation, it was found that the resident sleeping floor did not have a smoke barrier, which was confirmed by the Administrator during an interview. This deficiency affects one of two floors within the component and was identified through direct observation and staff confirmation. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency were provided in the report.
Smoke Compartment Size Exceeds NFPA 101 Standards
Penalty
Summary
The facility failed to comply with the NFPA 101 requirements for smoke compartments on the 1st floor, as observed during a survey conducted on April 22, 2023. The smoke compartment exceeded the maximum allowable size of 22,500 square feet, which is a violation of the standards set for smoke barriers in buildings with a patient bed capacity of 30 or more. This deficiency was confirmed during an exit interview with the Chief Executive Officer and Director of Campus Services on April 23, 2025.
Plan Of Correction
The facility will request the Division of Safety to conduct an FSES Survey.
Failure to Provide Complete Smoke Compartmentalization
Penalty
Summary
The facility failed to ensure that smoke barriers were provided to form at least two smoke compartments on every floor as required by applicable codes. During a record review, it was found that the facility did not provide a smoke barrier map that demonstrated complete compartmentalization by smoke barriers throughout the building. The map provided did not show smoke barriers separating smoke compartments from outside wall to outside wall in each compartment, as required. This finding was confirmed during an interview with Facility Maintenance at the time of the record review. No information about specific patients, their medical history, or their condition at the time of the deficiency was included in the report.
Plan Of Correction
K 371 Facility floor plan was reviewed and revised to include smoke compartments. Floor plans in the facility will be replaced to meet requirements. Maintenance Director was educated on K371 tag that floor plan must identify smoke barrier walls. Maintenance Director will review floor plans with any changes to ensure compliance with updates. Concerns observed will be addressed at the time of observation. Results of audits will be reported to QAPI Monthly x3 and PRN. Administrator is responsible for maintaining compliance.
Smoke Compartment Size Exceeds NFPA 101 Standards
Penalty
Summary
The facility failed to comply with NFPA 101 standards regarding the subdivision of building spaces into smoke compartments. Specifically, the smoke compartments on the 400 wing (zone two) and the First Floor (zone three), encompassing Rooms 101-111 and 101-302, exceeded the maximum allowable size of 22,500 square feet. This deficiency was identified through a combination of observation, document review, and interviews conducted on March 12, 2025. During the exit interview, the Administrator, Director of Maintenance, and Assistant confirmed that the smoke compartments were larger than permitted by the regulations.
Smoke Compartment Size Exceeds Maximum Allowance
Penalty
Summary
The facility failed to comply with the NFPA 101 requirements for smoke compartments, as evidenced by the C Wing smoke zone exceeding the maximum allowable area of 22,500 square feet. This deficiency was identified during an observation and document review conducted on January 27, 2025, at 8:30 a.m. The issue was confirmed during an exit interview with the Facility Administrator and Director of Maintenance later that morning. The deficiency affects one of the four smoke compartments within the facility, indicating a failure to ensure proper subdivision of building spaces for smoke control.
Facility Exceeds Maximum Smoke Compartment Size
Penalty
Summary
The facility failed to maintain smoke compartments within the required square footage, affecting three out of nine smoke compartments. During a document review and interview conducted on January 23, 2025, it was found that smoke compartments one, two, and five exceeded the maximum allowable area of 22,500 square feet. Specifically, smoke compartment one included Katharine, Drexel, and St. Anthony Avenue (300 & 400 Wings), smoke compartment two included St. Elizabeth's Garden and All Saints Boulevard (500 & 600 Wings), and smoke compartment five contained the Chapel and Administration offices, which are non-patient care areas. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director.
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