Failure to Maintain Smoke Barrier Integrity
Penalty
Summary
The facility failed to maintain the continuity of smoke barriers in accordance with NFPA 101 standards. During a facility tour conducted on February 11, 2025, between 1:00 p.m. and 4:00 p.m., it was observed that there was an unsealed penetration in the smoke barrier above the smoke door by room 106. Additionally, there was an untested blowout patching in the smoke barrier above the ceiling in the same area. These deficiencies were identified through both observation and interview with the maintenance director. The maintenance director acknowledged the presence of the unsealed penetration and the untested blowout patching during the tour. He stated that he had already removed several blowout patches but admitted that this particular one had not been addressed, and the barrier was not sealed to the deck. These findings were reviewed with both the maintenance director and the administrator during the exit conference on the same day.
Plan Of Correction
1. Identified unsealed penetration & smoke barrier has been sealed. Identified untested blowout patching in the smoke barrier above the ceiling has been removed/repaired. 2. Maintenance Director/Designee completed observation of other facility smoke barriers to verify they are maintained in accordance with NFPA 101. 3. The administrator provided education for current facility Maintenance Department regarding smoke barrier maintenance. 4. Maintenance Director/Designee to complete monthly observation of smoke barriers to verify they are maintained in accordance with NFPA 101. Findings to be reviewed at the monthly QAPI Committee Meeting. Modifications as indicated based on findings.