Smoke Barrier Wall Deficiencies on Second Floor
Penalty
Summary
During a Life Safety Code survey, it was observed that smoke barrier walls on the second floor of the facility were not properly maintained. Specifically, the smoke barrier walls were incomplete from floor to ceiling/roof deck, lacked a 30-minute fire resistance rating, and had open and unsealed penetrations that could allow the passage of smoke. One instance involved a piece of damaged drywall outside Resident Room 422, which was hanging loosely and required securing and re-caulking with fire-rated caulk. Another instance was found outside the Director of Nursing's Office, where a one-inch square penetration with a blue wire passing through it was observed. The Director of Facilities acknowledged the issues and noted that regular smoke barrier audits were not currently performed, although they had been conducted in the past during a construction project.
Plan Of Correction
Plan of Correction: Approved March 28, 2025 K372 Subdivision of Building Spaces – Smoke Barrier Construction 1. Corrective Action a. The Maintenance Department immediately secured the drywall piece and sealed the penetration using fire caulk in the smoke barrier outside of room 422 and sealed the penetration through the smoke barrier outside of the Director of Nursing’s office using fire caulk. b. Maintenance Staff were inserviced on inspection and maintenance of smoke barriers. 2. Identification of other smoke barriers having the potential to be affected The Director of Facilities and Maintenance Staff conducted a 100% audit of smoke barriers to ensure there were not any unsealed penetrations. 3. Systematic Changes The Director of Facilities and/or Maintenance Staff will conduct monthly audits of smoke barriers to ensure compliance. 4. Monitor Performance The Director of Facilities/designee will monitor monthly smoke barrier audits for 12 months. All audits will be reviewed quarterly at QA/QAPI meeting, and need for continuance after 12 months. 5. The Director of Facilities will be responsible for overall completion of the plan with respect to K372.