Smoke Barrier Wall Penetration Compromises Safety
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 April 8, 2025, at 11:20 AM, it was noted that there was an unprotected penetration in the smoke barrier wall on the 2nd floor. This penetration was located above the cross-corridor double doors near Resident Room 210 and involved a gray wire. This deficiency affected two out of eight smoke compartments within the component, compromising the smoke resistance of the barrier walls.
Plan Of Correction
1. The unprotected penetration of the second floor smoke barrier wall, above the cross-corridor double doors by resident room 210 around a gray wire was repaired using an approved through penetration fire stop system on 04-14-2025. The facility will maintain the rating of smoke barrier walls. 2. Maintenance Director, or designee, will audit weekly for two weeks, then monthly. Results of audits will be submitted to monthly QAPI for review and recommendations.