Deficiencies in Sprinkler System and Corridor Door Smoke Resistance
Penalty
Summary
The facility was found to have a deficiency related to the improper suspension of ductwork from the sprinkler system. On March 6, 2024, an observation was made at 10:46 AM, revealing that a length of flexible ductwork was suspended from the sprinkler piping above the suspended ceiling in the 1st floor Old Receptionist Room. This was confirmed through an interview with the Facilities Manager, who acknowledged the ductwork's suspension from the sprinkler system. This action compromises the integrity and functionality of the sprinkler system, which is critical for fire safety. Additionally, the facility failed to maintain the smoke resistance of corridor doors, which is essential for preventing the spread of smoke in the event of a fire. On March 6, 2025, at 11:08 AM, an observation revealed an unprotected penetration in the door to Room 102 on the 1st floor. This was confirmed in an interview with the Facilities Manager, who acknowledged the unprotected penetration. This deficiency affects one of the 27 smoke compartments within the facility, potentially compromising the safety of residents and staff in the event of a fire.
Plan Of Correction
1. The unprotected penetration on the first floor door to room 102 was filled with wood putty as this is a smoke door. 2. The maintenance department will be in-serviced by NHA/Designee on the importance of not having penetrations in doors within the facility. 3. Quarterly audits will be performed by the maintenance director/designee to ensure there are no penetrations in corridor doors. 4. Results of the audit will be reviewed/reported to the QA committee to determine trends and compliance. QA committee will determine need for continuance of audits.