Failure to Maintain Smoke Barrier Wall Integrity
Penalty
Summary
The facility failed to maintain the smoke resistance of smoke barrier walls, which is a requirement for ensuring safety in the event of a fire. During an observation on January 27, 2025, at 10:40 AM, it was discovered that there was an unprotected penetration in the smoke barrier wall on the 2nd floor. This penetration was located above the suspended ceiling, near the cross corridor double doors by the T.V. Lounge, and beneath a sprinkler pipe. The Senior Maintenance Director confirmed the presence of this unprotected penetration during an interview conducted at the same time.
Plan Of Correction
1. The penetration was sealed using an approved through penetration fire stop system on 2/3/25. 2. Maintenance Director will inspect all smoke and fire walls throughout the facility by 2/7/25. Any penetrations found will be sealed using an approved penetration fire stop system. 3. All smoke barrier walls will be inspected quarterly and after any contractor completes work that may impact the walls. 4. Facility will maintain the rating of the smoke barrier walls. 5. Findings will be reported to QAPI for review and discussion.