Failure to Maintain Fire/Smoke Barrier Integrity in Electrical Room
Penalty
Summary
During an unannounced Fire & Life Safety revisit survey, surveyors observed that the facility failed to maintain proper fire and smoke barrier construction in accordance with NFPA 101 standards. Specifically, in Electrical Room #6, there were five open conduit penetrations through the south side 1-hour fire rated wall and three penetrations through the north side smoke wall. Additionally, thirteen areas on the east and south side 1-hour fire rated walls were found with red fire stopping mixed with a white putty, as well as areas with only white putty surrounding the penetrating conduit. The facility was unable to provide documentation confirming that the white putty used was approved for fire stopping purposes. These deficiencies were identified during a fire safety tour conducted with the Administrator and the Maintenance Director, who acknowledged the findings at the time of observation. The surveyors noted that these examples may not represent all unprotected penetrations in the facility's fire and smoke barriers, emphasizing the need for a thorough inspection of each barrier along its full length and height to ensure all penetrations are properly sealed. The report further states that every breach or penetration of a fire barrier must be appropriately repaired to restore the wall, ceiling, or floor to its original fire or smoke rated integrity. The penetrations in fire rated barriers are required to be sealed with a UL (Underwriters Laboratories) listed approved system. Photographic evidence was obtained to document the observed deficiencies.
Plan Of Correction
6/6/25 Preparation and/or execution of this plan of correction does not constitute admission or agreement of the provider of the truth of the alleged or conclusion set forth in the CMS measured star ratings. The plan of correction is prepared and executed solely because it is required by Federal and State Laws. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. No residents were affected by this alleged deficient practice. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: 2. The facility will maintain the fire/smoke barrier construction in Electrical room #5. Penetration holes five (5) through the South side; three through the North side smoke wall; thirteen (13) areas on the East and South side 1-hour fire rated walls were resealed by a 3M trained professional in accordance with NFPA 101. A thorough inspection of each fire/smoke barrier will be conducted to ensure that all penetrations are found and properly sealed in accordance with NFPA 101. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: 3. Maintenance staff re-educated on ensuring fire/smoke barrier penetrations are inspected along its full length, height and properly sealed with a UL (Underwriters Laboratories) listed approved system. 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 in place: 4. Maintenance Director or Designee will report the findings of fire/smoke barrier penetrations audits to the QAA&C monthly times three months or until substantial compliance is met. Preparation and/or execution of this plan of correction does not constitute admission or agreement of the provider of the truth of the alleged or conclusion set forth in the CMS measured star ratings. The plan of correction is prepared and executed solely because it is required by Federal and State Laws. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. No residents were affected by this alleged deficient practice. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: 2. The facility will maintain the fire/smoke barrier construction in Electrical room #5. Penetration holes five (5) through the South side; three through the North side smoke wall; thirteen (13) areas on the East and South side 1-hour fire rated walls were resealed by a 3M trained professional in accordance with NFPA 101. A thorough inspection of each fire/smoke barrier will be conducted to ensure that all penetrations are found and properly sealed in accordance with NFPA 101. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: 3. Maintenance staff re-educated on ensuring fire/smoke barrier penetrations are inspected along its full length, height and properly sealed with a UL (Underwriters Laboratories) listed approved system. 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 in place: 4. Maintenance Director or Designee will report the findings of fire/smoke barrier penetrations audits to the QAA&C monthly times three months or until substantial compliance is met.