Unsealed Penetration in Smoke Barrier Wall
Penalty
Summary
During a facility tour and staff interview, surveyors observed that the smoke barrier wall above the fire doors near Room 12 had an unsealed penetration measuring approximately two inches in diameter, which contained a metal conduit. This condition was confirmed by a staff member, who acknowledged that he had not yet inspected the smoke barrier walls. The unsealed penetration compromised the smoke integrity of the barrier wall, which is required to have a minimum 1/2-hour fire resistance rating according to NFPA 101, Life Safety Code, 2012 Edition. This deficiency affected 27 out of 92 residents and one of six smoke compartments in the facility. The report does not mention any specific medical history or condition of the residents involved, but it directly states that the unsealed penetration could result in the spread of smoke in the event of a fire. The deficiency was identified through direct observation and staff confirmation during the survey.
Plan Of Correction
K 372 - Smoke Barrier Construction How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: • The identified penetration was sealed using fire-rated caulking and fire-resistant materials in accordance with NFPA 101 and NFPA 8.5.6.2 standards. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: • No other residents have the potential to be affected. The penetration was limited to its specified smoke compartment. • A comprehensive review of all smoke barrier walls was conducted to identify any other unsealed penetrations. No other issues were found. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: • A quarterly smoke barrier inspection protocol has been implemented, with documentation maintained for compliance review. • The EVS Director was trained by the administrator on the importance of proper inspection and sealing of smoke barrier penetrations. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system; • Results will be reviewed in the QAPI meetings for ongoing compliance oversight. Date of Compliance 4/18/25