Incomplete Smoke Barriers in Facility
Penalty
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.