Unsealed Smoke Barriers in Facility
Penalty
Summary
The facility failed to ensure that penetrations in smoke barriers were adequately sealed, as required by the NFPA 101 Life Safety Code (2012 Edition) Section 8.5. During observations conducted on January 7, 2025, several unsealed gaps and overcuts were identified in various locations throughout the facility. These included a two-inch unsealed overcut around conduit penetrations near the Dining Room, a similar unsealed overcut around wire penetrations by Room 210, and a six-inch unsealed gap at the top of the wall in the Korean Office. Additional unsealed gaps were found in the Break Room and near the Beauty Salon. The deficiency was confirmed during an interview with a facility representative, who acknowledged the findings and admitted that the facility was unaware of the unsealed gaps and penetrations in the smoke barriers. This issue was a repeat deficiency, having been previously cited during the Life Safety Code Survey conducted on September 29, 2023. The unsealed penetrations in the smoke barriers had the potential to affect all 131 residents in the facility.
Plan Of Correction
Element 1 This deficiency was corrected by sealing all openings within the smoke barriers including: the two inch overcut around two conduit penetrations above the ceiling located in the corridor by the dining room, the two inch overcut around the blue wire penetrations above the ceiling located in the corridor by room 210, the six inch gap at the top of the wall above the ceiling located inside the Korean Office, the two inch gap at the top of the wall above the ceiling located inside the break room, and the four inch gap in the wall above the ceiling located in the corridor by the Beauty Salon. Element 2 All residents have the potential to be affected by this deficiency. Element 3 A Smoke Barrier audit is being conducted by the Maintenance Director to ensure that the facility remains in compliance with K372. This audit will be completed by making rounds within the facility to view the smoke barriers. Element 4 The Smoke Barrier audit is being monitored by the Administrator or designee once a week for two months, then once every other week for two months, and then once a month for two months. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.