Deficiencies in Smoke Barrier Wall Maintenance
Summary
During a Life Safety Code survey, it was observed that the smoke barrier walls in the Occupational Therapy/Physical Therapy room and the main corridor were not maintained as required. Specifically, the smoke barrier walls were incomplete from floor to ceiling deck, lacked a 30-minute fire resistance rating, and were unable to resist the passage of smoke due to penetrations. In the Occupational Therapy/Physical Therapy room, a six-inch by six-inch open penetration and a three-foot by three-foot area of removed gypsum board were found. Additionally, a 22-foot by three-foot section of the smoke barrier wall was missing, exposing an unprotected steel beam. Further observations in the main corridor revealed a two-inch by two-inch penetration around electrical wires filled with orange foam, which the Facilities Director stated was not used by the facility. Another two-inch by two-inch open penetration was found around a gray electrical wire. The Facilities Director was unaware of these issues and stated that the Occupational Therapy/Physical Therapy room was undergoing remodeling. The architectural drawings confirmed that these walls were part of the facility's smoke barrier system, labeled as Smoke Area D, and were intended to provide fire and smoke protection.
Plan Of Correction
Plan of Correction: Approved February 6, 2025 Smoke Barrier walls in identified locations were not completely sealed from ceiling to roof deck. The Facilities Director had both the Facility Manager and Facility Supervisor seal all penetrations identified and sealed the open penetrations with fire sealant that is capable of maintaining the smoke resistance of the smoke barrier and meets the current NFPA standards. The Facilities Director inspected each area to ensure code compliance. All residents have the potential to be affected. The Facilities Director has reviewed requirements regarding smoke barriers. A review of the requirements of smoke barriers was also conducted by the Facilities Director with the Facility Manager and Facility Supervisor. The Facilities Supervisor will inspect all smoke barriers as part of the monthly environmental inspections. The Facilities Director will conduct monthly reviews of the inspection reports completed by the Facility Supervisor. The monthly inspections will be submitted by the Facilities Director at the bi-monthly Quality Assessment & Performance Improvement (i.e., QAPI) Committee meetings. The Facilities Director will be responsible for the ongoing compliance of this plan.
Penalty
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