Deficiencies in Fire/Smoke Barrier Construction
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 April 30, 2025, several deficiencies were observed in the smoke barriers of the facility. Specifically, the Reflection Wing's 1-hour smoke wall near Room 106 had five penetrations above the ceiling, and near Room 104, there were three penetrations. Additionally, the Seaway Wing's 2-hour fire-rated wall near Room 206 had four penetrations above the ceiling. These penetrations in the smoke barriers compromise the integrity of the fire resistance rating, which is crucial for restricting the movement of fire and smoke in the event of an emergency. The Plant Operations Technician acknowledged these findings during the inspection, and the issues were communicated to the Administrator and the Director of Plant Operations during the exit conference. The report emphasizes that these examples are not exhaustive, and a thorough inspection of each barrier should be conducted to ensure all penetrations are identified and properly sealed. The penetrations in fire-rated barriers must be sealed with a UL-listed approved system to restore the original fire or smoke-rated integrity of the walls, ceilings, and floors.
Plan Of Correction
No residents were affected by this alleged deficient practice as of 05/16/2025 and none can be identified as of 05/16/2025. The maintenance director and assistants were educated by the Executive Director on 05/16/2025 on K372. The center smoke walls were inspected above the ceilings throughout the center on 05/16/2025 to identify any other penetrations needing to be sealed by the maintenance director/designee. 1. The Reflection Wing 1-hour smoke wall, near Room 106, had the five penetrations above the ceiling repaired on 05/20/25 by the maintenance director/designee. 2. The Reflection Wing 1-hour smoke wall, near Room 104, had the three penetrations above the ceiling repaired on 05/20/25 by the maintenance director/designee. 3. The Seaway Wing 2-hour fire rated wall, near Room 206, had the four penetrations above the ceiling repaired on 05/20/25 by the maintenance director/designee. Fire penetrations above the ceiling will be audited for compliance with K372 by the maintenance director/designee weekly x4 weeks, monthly x6 months and the results of these audits will be brought to QAPI for review. No residents were affected by this alleged deficient practice as of 05/16/2025 and none can be identified as of 05/16/2025. The maintenance director and assistants were educated by the Executive Director on 05/16/2025 on K372. The center smoke walls were inspected above the ceilings throughout the center on 05/16/2025 to identify any other penetrations needing to be sealed by the maintenance director/designee. 1. The Reflection Wing 1-hour smoke wall, near Room 106, had the five penetrations above the ceiling repaired on 05/20/25 by the maintenance director/designee. 2. The Reflection Wing 1-hour smoke wall, near Room 104, had the three penetrations above the ceiling repaired on 05/20/25 by the maintenance director/designee. 3. The Seaway Wing 2-hour fire rated wall, near Room 206, had the four penetrations above the ceiling repaired on 05/20/25 by the maintenance director/designee. Fire penetrations above the ceiling will be audited for compliance with K372 by the maintenance director/designee weekly x4 weeks, monthly x6 months and the results of these audits will be brought to QAPI for review.