Deficiencies in Smoke Barrier Wall Maintenance
Summary
During a Life Safety Code survey, it was observed that smoke barrier walls in a long-term care facility were not properly maintained, leading to deficiencies in fire safety. The smoke barrier walls on the second floor of both the front and rear buildings were found to have unsealed penetrations, which compromised their ability to resist the passage of smoke. Specifically, a penetration in the smoke barrier wall at the resident lounge measured two inches wide by three inches high, with a white wire running through it. The Assistant Maintenance Director was unaware of this penetration, and the Maintenance Director identified the wire as a telephone line installed by an outside vendor. Additionally, other penetrations were found with improper sealing materials, such as orange expandable foam, which was not typically used by the facility's maintenance staff. Further observations revealed that the smoke barrier walls had been compromised by the use of non-compliant materials. A small cluster of yellow wires outside the shower room and a wire outside resident room 242 were improperly sealed with orange expandable foam, which was not fire-rated. The Maintenance Director acknowledged that the foam might have been used by an outside vendor, as the facility had previously purchased a non-compliant product, Brand A Fire Block Foam FB-Foam, which was not suitable for rated construction. The lack of regular audits of smoke barrier walls by maintenance staff contributed to the oversight of these deficiencies.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 The unsealed penetration through the smoke barrier wall at the resident lounge on the second floor of the rear building was sealed. The penetration noted in the smoke barrier wall outside of the shower room on the second floor of the rear building was sealed properly and orange foam was removed. The penetration noted in the smoke barrier wall outside of resident room 242 was properly sealed and the orange foam was removed. The penetration noted in the smoke barrier wall outside of resident room 209 was properly sealed and the orange foam was removed. An audit was conducted throughout the rear and front buildings to ensure no other penetrations noted in the smoke barrier walls. The maintenance director and the maintenance staff were educated on the Smoke Barrier requirement in accordance with NFPA 101 and on facility policy “maintenance-preventative” that smoke barriers are to be inspected monthly. The policy and procedure were reviewed and no changes were made. An audit tool was created to ensure inspections on smoke barriers are completed timely. The Maintenance Director will audit one unit of smoke barrier walls monthly for 5 months in both buildings. Results of the audits will be reviewed at QAPI. The Maintenance Director is responsible for the plan.
Penalty
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