Deficiencies in Smoke Barrier Wall Construction
Penalty
Summary
During a Life Safety Code recertification survey conducted on two consecutive days in 2025, deficiencies were identified in the construction of smoke barrier walls within the facility. Specifically, the survey revealed that the smoke barrier walls on two of the six resident floors did not meet the required ½-hour fire resistance rating as stipulated by NFPA 101. Observations included an opening of approximately 2 inches around two armored cables on the 5th floor adjacent to a resident room, a missing cover on a junction box adjacent to another resident room, and a penetration of approximately 1 inch around multiple cables on a different floor. These deficiencies were noted during the survey, and the Director of Maintenance acknowledged the issues, indicating that the penetrations would be sealed with fire-stop material. The report highlights that the facility did not ensure the smoke barrier walls were constructed to provide the necessary fire resistance, as required by the relevant fire safety codes.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The Director of Maintenance permanently sealed the identified penetrations above the ceiling tiles in the smoke barrier walls on the 5th Floor adjacent to resident room 506, adjacent to resident room 417, adjacent to resident room 217 with approved rated fire stop material on 2/10/2025. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility acknowledges that residents have the potential to be affected by this practice. The Director of Maintenance checked all smoke barriers for penetrations. No deficiencies were identified. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: All maintenance staff will receive additional education, and all participants will understand the life safety issues with smoke barrier requirements in accordance with the requirements of NFPA 101 2012 edition 19.3.7.3 and 8.5.6.2. A audit tool was developed to inspect smoke barriers for penetration. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a weekly basis, for one quarter, the Dir. Maintenance or designee will audit all smoke barriers for penetrations to ensure compliance. Any outstanding issues will be addressed immediately and reported to the Administrator. On a monthly basis, for one quarter, the Director of Maintenance or Designee will review monthly audits and report findings to Administrator. On a quarterly basis, the Director of Maintenance or Designee will report the result of the audits to the QAPI. 5. The title of the person responsible for correction of each deficiency: Administrator, Director of Maintenance.