Fire/Smoke Barrier Deficiency
Penalty
Summary
The facility failed to maintain their fire/smoke barrier construction in accordance with NFPA 101 standards. During a fire safety tour conducted on March 19, 2025, with the Maintenance Director, surveyors observed penetrations in the fire/smoke barriers at two locations within the facility. Specifically, at 12:52 PM, a penetration was found through both sides of a 2-hour fire-rated wall in the Galilee wing near Room 233. Additionally, at 2:09 PM, another penetration was identified through both sides of a smoke wall in the Masada wing near Room 127. The Maintenance Director acknowledged these findings during the tour, and the observations were reviewed with both the Administrator and the Maintenance Director at an exit conference later that day. The report notes that these examples are not exhaustive, suggesting that other unprotected penetrations may exist within the facility's fire/smoke barriers. It emphasizes the importance of conducting a thorough inspection of each barrier along its full length and height to ensure all penetrations are identified and properly sealed. The report underscores the necessity of maintaining the integrity of fire and smoke barriers to restrict the movement of fire and smoke, thereby ensuring the safety of the facility's occupants in the event of a fire emergency. It specifies that any breaches in fire-rated barriers must be repaired using a UL-listed approved system to restore the original fire or smoke-rated integrity of the walls, ceilings, or floors involved.
Plan Of Correction
NFPA 101 SUBDIVISION OF BUILDING SPACES SMOKE BARRIER 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of the Galilee wing, near room 233 having one penetration through both sides of the smoke wall. Maintenance will seal the penetration with Red Fire Caulk. 2) In the allegation of the Masada wing, near room 127 having one penetration through both sides of the smoke wall. Maintenance will seal the penetration with Red Fire Caulk. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Maintenance will seal the alleged penetration in the smoke walls with Red Fire caulk. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee, will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction. Corrective action completion date: 4/19/25 K372 SUBDIVISION OF BUILDING SPACES-SMOKE BARRIER 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of the Galilee wing, near room 233 having one penetration through both sides of the smoke wall. Maintenance will seal the penetration with Red Fire Caulk. 2) In the allegation of the Masada wing, near room 127 having one penetration through both sides of the smoke wall. Maintenance will seal the penetration with Red Fire Caulk. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Maintenance will seal the alleged penetration in the smoke walls with Red Fire caulk. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee, will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction.