Unprotected Penetration in Smoke Barrier Wall
Penalty
Summary
The facility failed to maintain the smoke resistance of smoke barrier walls as required by NFPA 101. During an observation, an unprotected penetration was found in the Zone 11 smoke barrier wall, located above the double doors near the ADON/Medical Records Office, where blue and red wires passed through the wall without proper protection. This deficiency was confirmed during an interview with the Director of Maintenance, who acknowledged the unprotected penetration. The issue affected two of twelve smoke compartments within the component. No information about residents, their medical history, or their condition at the time of the deficiency is provided in the report.
Plan Of Correction
The smoke barrier wall was repaired using an approved through-penetration fire stop system. The facility will maintain the rating of the smoke barrier walls moving forward. Maintenance staff will be educated on ensuring penetrations are protected and maintaining the rating within smoke barrier walls. Maintenance Director/Designee to perform random quarterly audits for 1 year on smoke barrier walls. Results of audits will be forwarded to the QAPI Committee.