Smoke Infiltration from Burnt HVAC Filter Due to Roofing Torch Work
Penalty
Summary
The facility failed to ensure a safe environment free of accident hazards when smoke from a burnt HVAC unit filter entered an interior hallway leading to the front lobby. On 1/10/2026, multiple staff, including the DON, LVNs, CNA, Activity Director, maintenance staff, and the receptionist, reported smelling something burning, detecting smoke or haze in the hallway, and noting a burnt or plastic-like odor. The DON stated he was notified at 10:59 AM by an RN that there was smoke inside the facility, and paramedics who were on-site for a resident’s change of condition also noticed smoke in the building. Staff reported that the smoke detector did not alarm during the event. The Maintenance Director reported that maintenance staff informed him of smoke and a burning smell, traced to a ceiling vent connected to HVAC unit 15. During observation with the Administrator, HVAC unit 15’s filter was found partially burnt, and the Administrator explained that roofing workers using a torch to patch the roof ignited the HVAC filter, causing smoke to travel down the vent into the facility. Staff interviews confirmed that residents’ doors were ordered closed in response to the smoke and that paramedics assisted by opening the front door and turning on fans in the hallway. The DON and LVNs acknowledged that smoke inhalation is harmful and can cause respiratory distress, particularly for residents with underlying respiratory conditions. Review of the facility’s Accidents/Incidents policy indicated the facility is required to provide a safe and secure environment for staff and residents, which was not maintained when smoke entered the occupied hallway and the smoke detection system did not alarm.
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