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 fire safety within the building. During an observation, it was noted that there were two unprotected penetrations in the basement Linen Storage Room wall, where two pipes had been removed. This deficiency was confirmed through an interview with the Maintenance Manager, who acknowledged the unprotected penetrations of the smoke barrier wall. This issue affected two out of the 14 smoke compartments within the component, compromising the smoke resistance of the barrier walls.
Plan Of Correction
The two penetrations of the basement Linen Storage Room will be corrected by the Maintenance Manager using an approved through penetration fire stop system. The Maintenance Manager or designee will conduct an audit of corridor walls weekly for one month, then bi-weekly for one month. Monthly fire walls inspections will be added to PM schedule to check for penetrations and caulking in place and ensure that the facility is maintaining the rating of the smoke barrier wall. Deficient findings will be reported to DES and QAPI meeting.