Unsealed Penetrations in Smoke Barrier Walls
Penalty
Summary
During a Life Safety Code survey, it was observed that smoke barrier walls in the facility were not maintained as required. Specifically, the smoke barrier walls on both the first and second floors were found to have unsealed penetrations, which compromised their ability to resist the passage of smoke and maintain a 30-minute fire resistance rating. On the second floor in the Cedar Unit, a two-inch long by one-inch wide open penetration was found above the smoke barrier doors. Similarly, on the first floor in the Evergreen Unit, a 16-inch long by three-inch wide open penetration was observed. The Maintenance Supervisor confirmed that no recent work had been conducted on these walls and stated that the facility's smoke barrier walls were inspected twice a year, although no documentation of these inspections was available.
Plan Of Correction
Plan of Correction: Approved February 26, 2025 Q1. Per the Directed Plan of Correction, the following actions were accomplished for the residents identified in the sample. - No residents were negatively impacted. - Penetrations were sealed in the smoke barrier wall above the smoke barrier doors separating Cedar Unit from the second floor corridor. - Penetrations were sealed in the smoke barrier wall above the smoke barrier doors separating the Evergreen Unit from the first floor corridor. Q2. Per the Directed Plan of Correction, the following corrective actions will be implemented to identify other residents who may be affected by the same practice: - All residents have the potential to be affected. - A visual inspection of the facility will be conducted to ensure all visible penetrations are properly sealed. Q3. Per the Directed Plan of Correction, the following system changes will be implemented to ensure continuing compliance with regulations: - The facility fire protection policy was reviewed by the consultant with Administration and the Director of Maintenance without changes. - As per the Directed Plan of Correction, the Consultant has developed and implemented an In-service Program to address - All maintenance staff will be re-educated on the policy specific to ensuring thorough inspection of the facility to ensure all areas of penetrations are identified and properly sealed by the consultant. - All training components have been added to the initial orientation and annual education for facility maintenance staff. Q4. The facility’s compliance will be monitored utilizing the following quality assurance system: As per the Directed Plan of Correction, a Quality Assessment & Assurance Committee meeting was held on (MONTH) 24, 2025, to examine this deficiency. - The Director of Maintenance will inspect any areas of contractor work for potential areas of penetrations immediately following the conclusion of scope of work. - The Director of Maintenance will provide quarterly reports on contracted work and subsequent inspections to the Quality Assurance Performance Improvement committee for the next 12 months. - Frequency of ongoing audits will be determined by the Committee based on audit results. - The consultant will participate in the Quality Assessment & Assurance Committee Meeting monthly x 3 months. Responsibility: The Director of Maintenance