Smoke Barrier Deficiencies Due to Ceiling Tile Issues
Summary
The facility failed to maintain smoke barriers in over thirty rooms, affecting the entire component. During an observation conducted on January 22, 2025, between 8:45 a.m. and 10:15 a.m., it was noted that multiple ceiling tiles on the main floor were not properly maintained. These tiles were found to be loose, misaligned, damaged, or missing in various locations. Additionally, five rooms in the basement area were impacted by a recently frozen and ruptured pipe, which caused water damage to numerous ceiling tiles. The damaged tiles were removed to address the water damage and to facilitate repairs to the piping. The absence of these ceiling tiles could potentially delay the activation of fire system components and allow smoke to pass through. The maintenance supervisor confirmed these deficiencies during an interview at the time of the survey.
Plan Of Correction
Maintenance replaced damaged and deficient ceiling tiles. Maintenance completed a whole house audit to identify deficient ceiling tiles. NHA/Designee to educate maintenance staff by 21MAR2025 on the importance of ceiling tiles to ensure proper function for smoke barrier. Maintenance/designee to complete audits weekly x 4 of ceiling tiles. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. Fire Drill conducted immediately following the safety survey. No negative findings identified.
Penalty
Surveyors found that smoke/fire-rated enclosures were not properly maintained, with penetrations in smoke barriers in several general storage rooms across multiple smoke compartments. The Maintenance Director stated that insulation and fiberglass were used to pack and cover these holes but could not confirm that the materials were approved for fire-rated construction. Inspectors observed penetrations covered with fiberglass and noted a hole in one fiberglass panel in a storage room, resulting in a deficiency under NFPA 101 requirements for smoke barrier construction.
Surveyors found that smoke/fire barriers in three of fourteen smoke compartments, including the hot water room, the barrier between the kitchen and a smoke compartment, and the smoke wall leading to the Alzheimer’s unit, had penetrations that were not properly fire-stopped. During the on-site interview, the Maintenance Director acknowledged that recent electrical work had been completed and that the contractor failed to seal these penetrations, resulting in noncompliance with NFPA 101 smoke barrier construction requirements.
A deficiency was identified when an unsealed penetration around data wires was observed in a smoke barrier wall on the second floor near the Rehabilitation Department. This issue was confirmed by the Administrator and Maintenance Director and affected one of two floors.
An unprotected penetration was found in a smoke barrier wall above double doors near the ADON/Medical Records Office, where blue and red wires passed through without proper protection. This issue, confirmed by the Director of Maintenance, affected two of twelve smoke compartments.
Surveyors found that two wires passed unsealed through a smoke barrier above the ceiling near a resident corridor, with the Maintenance Director confirming unawareness of the sealing requirement. This deficiency had the potential to affect five residents and did not comply with NFPA 101-2012 standards for smoke barrier construction.
Surveyors found multiple penetrations in smoke barriers sealed with non-fire-rated materials and one unsealed pipe, compromising the required fire and smoke resistance in several corridors and the attic. Maintenance leadership confirmed uncertainty about the materials used, and these deficiencies had the potential to affect all 39 residents.
Improper Repair of Smoke Barrier Penetrations in Multiple Smoke Compartments
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of smoke/fire-rated enclosures, specifically related to penetrations in smoke barriers in multiple smoke compartments. During an interview, the Maintenance Director reported that insulation was used to pack holes and then covered with fiberglass in general storage rooms in smoke compartments 1, 2, and 3, but was unable to confirm whether these materials were approved for use in fire-rated walls. Subsequent observation showed that the penetrations were indeed covered with fiberglass, and one general storage room in smoke compartment 2 had a hole in one of the fiberglass panels. The report states that this failure to properly maintain penetrations through smoke/fire-rated construction could allow smoke and flammable gases to spread to other areas and cause the smoke/fire-rated construction to fail to perform as designed.
Unsealed Penetrations in Smoke/Fire Barriers After Electrical Work
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of smoke/fire-rated enclosures, specifically related to unsealed penetrations in smoke/fire barriers. During an observation on 4/27/2026 between 2:30 PM and 2:45 PM, surveyors found that the hot water room, the smoke barrier dividing the kitchen and smoke compartment 1, and the smoke wall leading to the Alzheimer’s unit all had penetrations that were not properly fire-stopped. These conditions were determined to affect 3 out of 14 smoke compartments in the building. During an interview conducted at the time of the observation, the Maintenance Director acknowledged the findings. The Maintenance Director stated that new electrical work had been performed and that the contractor had forgotten to properly seal the penetrations. The Maintenance Director also acknowledged the specific issues identified in the hot water room. The deficiency was cited under NFPA 101 (2021 Edition) 19.3.7.3 and 8.5.6, Class III, for failure to maintain the required smoke/fire barrier construction.
Unsealed Penetration in Smoke Barrier Wall
Penalty
Summary
The facility failed to maintain smoke barrier walls free of unsealed penetrations, as required by NFPA 101 standards. During an observation on the second floor above the double doors near the Rehabilitation Department, an unsealed penetration was found around data wires. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director. The issue affected one of two floors in the building. No information regarding residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
Unsealed penetration data wires around double doors by Rehabilitation office were sealed with fire stop compound. The maintenance director/designee will perform weekly safety rounds to ensure there are no ceiling penetrations that need to be sealed. Maintenance director/designee will report on the corrective action monthly x 6 months during QAPI.
Unprotected Penetration in Smoke Barrier Wall
Penalty
Summary
The facility failed to maintain the smoke resistance of smoke barrier walls as required by NFPA 101. During an observation, an unprotected penetration was found in the Zone 11 smoke barrier wall, located above the double doors near the ADON/Medical Records Office, where blue and red wires passed through the wall without proper protection. This deficiency was confirmed during an interview with the Director of Maintenance, who acknowledged the unprotected penetration. The issue affected two of twelve smoke compartments within the component. No information about residents, their medical history, or their condition at the time of the deficiency is provided in the report.
Plan Of Correction
The smoke barrier wall was repaired using an approved through-penetration fire stop system. The facility will maintain the rating of the smoke barrier walls moving forward. Maintenance staff will be educated on ensuring penetrations are protected and maintaining the rating within smoke barrier walls. Maintenance Director/Designee to perform random quarterly audits for 1 year on smoke barrier walls. Results of audits will be forwarded to the QAPI Committee.
Unsealed Wire Penetrations in Smoke Barrier
Penalty
Summary
During a facility tour, surveyors observed that one grey wire and one white wire were passing through a smoke wall without being properly sealed in the space between the drop ceiling and the building ceiling at the double corridor by room B-9. This unsealed penetration was found in an area that serves as a smoke barrier, which is required by NFPA 101-2012 to be constructed with a minimum 1/2-hour fire resistance rating and to restrict the transfer of smoke. The observation was made in the presence of the Maintenance Director, who confirmed the finding and stated he was unaware of the requirements for sealing such penetrations. The deficiency had the potential to affect five out of 46 residents in the facility. The report cites specific NFPA 101-2012 code sections that require all penetrations in smoke barriers, including those for wires, to be protected by a system or material capable of restricting smoke transfer. The failure to seal the wire penetrations in the smoke barrier constituted noncompliance with these requirements.
Plan Of Correction
K0372 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 07/30/25 as the facility's allegation of compliance date. The facility failed to ensure smoke barrier in Rm #B9 would resist passage of smoke. Step 1 Penetrations in Rm#B9 were sealed to resist passage of smoke to prevent passage of smoke creating a sealed/contained smoke compartment 6-6-25. Step 2 All resident rooms audited for penetrations by 7/15/25. Step 3 Maintenance Director educated by LNHA on the smoke barrier function of the ceiling and maintaining the integrity of the ceiling 7/15/25. Step 4 To monitor and maintain compliance, LNHA/designee will audit smoke barriers for compliance weekly for X4, then monthly X2. Results of the audits will be forwarded to the facility QAPI committee for further review and recommendation. K0374 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 07/30/25 as the facility's allegation of compliance date. The facility failed to maintain fire/smoke barrier doors by DON office and room R1. Fire/Smoke barrier door by A4 and A9 failed to close during test of fire alarm. Step 1 Maintenance Director repaired the doors by DON office and room R1 and A4 and A9 6-6-25. Step 2 Fire doors audits for compliance by Maintenance Director 6-6-25, no negative findings. Step 3 Maintenance Director educated by LNHA on the Fire/Smoke Barrier Doors by 7-15-25. Step 4 To monitor and maintain compliance, LNHA/designee will audit fire/smoke barriers doors for compliance weekly for X4, then monthly X2. Results of the audits will be forwarded to the facility QAPI committee for further review and recommendation.
Failure to Maintain Smoke Barrier Integrity per NFPA 101
Penalty
Summary
The facility failed to maintain fire and smoke barriers in accordance with NFPA 101-2012 Edition, Section 19.3.7.3 and Section 8.5.6.2. During a facility tour, surveyors observed multiple penetrations in smoke barriers that were improperly sealed with non-fire-rated, rubber-like materials. These penetrations included aluminum conduits and black pipes located in the interstitial spaces between the ceiling and drop ceiling above several 20-minute fire-rated double corridors leading into various halls, including the 100, 200, 300, and 400 Halls, as well as the Service Hall. Additionally, one 3-inch black pipe was found completely unsealed in the attic space above a fire-rated double corridor leading into the attic. The materials used to seal the other penetrations were not fire-rated and did not meet the requirements for restricting the transfer of smoke as specified by the referenced NFPA standards. The Regional Maintenance Director confirmed at the time of discovery that he was unsure of the type of material used to seal the pipes. These deficiencies were identified during direct observation and staff interviews, and the findings were confirmed by facility maintenance leadership. The report notes that these failures had the potential to affect all 39 residents in the facility, as the integrity of the smoke barriers was compromised by the use of improper sealing materials and the presence of unsealed penetrations.
Plan Of Correction
Tag: K 0372 Both the pipe and conduits between the ceiling and drop ceiling above the fire-rated double corridor leading into 100 hall, 200 hall, 300 hall, 400 hall, service hallway, and into the attic space were repaired with fire-rated caulk on or before 6/20/25. There was no other conduit or pipes found to have penetrations not properly sealed. Administrator educated maintenance director on NFPA 101 subdivision of building spaces - smoke barrier construction on 6/16/25. Maintenance director or designee will audit pipes and conduits for penetration monthly x 3 months. Audits will be submitted to the QAPI committee for review and recommendations. K 0372
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