Deficiency in Smoke Barrier Wall Construction
Penalty
Summary
The facility failed to ensure that smoke barrier walls were constructed to provide at least a one-half-hour fire resistance rating as required by NFPA 101. During a Life Safety Code recertification survey, surveyors observed deficiencies in the smoke barrier walls on two of the eight resident floors. Specifically, on the 13th Floor adjacent to resident room 1314, there was an opening of approximately 1/8 inch around a 1-inch metal pipe. Additionally, on the 11th Floor adjacent to resident room 1126, a penetration of approximately 4 inches by 4 inches was found. These observations indicate that the smoke barrier walls were not adequately sealed to restrict the transfer of smoke, as required by the relevant fire safety codes. The Director of Maintenance acknowledged the issue during an interview at the time of the observation, noting that the pipe would be sealed with fire stop material. However, the report does not provide details on any corrective actions taken at the time of the survey.
Plan Of Correction
Plan of Correction: Approved January 31, 2025 K372 Smoke Barrier Walls 1. What Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: The opening observed in the smoke barrier wall of approximately 1/8 inch around a 1-inch metal pipe on the 13th Floor adjacent to resident room 1314 was sealed with a fire stop material. The opening observed in the smoke barrier wall of approximately 4 inches x 4 inches on the 11th Floor adjacent to resident room 1126 was sealed with a fire stop material. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: An audit of all smoke barrier walls throughout the facility was conducted to ensure all openings are correctly sealed with fire stop material. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: A system for a regular review of the smoke barrier walls was developed. The Director of Maintenance will oversee the sealing of the openings and the audit of the smoke barrier walls. 4. How the Corrective Action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice: The Director of Maintenance/Designee will gather the data from the audit of the smoke barrier walls and report findings to the QAPI Committee for a period of 3 months to ensure the smoke barrier walls are compliant. 5. Responsible Individual: Director of Maintenance