Deficiencies in Smoke Barrier Wall Maintenance
Summary
During a Life Safety Code survey, it was observed that the smoke barrier walls in Unit 5 of the facility were not properly maintained. Specifically, the walls were not complete from floor to roof deck, lacked a 30-minute fire resistance rating, and were not designed to resist the passage of smoke due to penetrations. These deficiencies were identified in several locations: a two-inch by one-inch penetration near a steel support beam above the smoke barrier doors near Resident Room 519, a four-inch by two-inch area filled with mineral wool but not sealed with fire-rated material above the smoke barrier doors near Resident Room 522, and a five-inch by three-inch penetration near plumbing pipes below the sink in the bathroom of Resident Room 522. Interviews with the Maintenance Director revealed a lack of awareness regarding the penetration below the sink in Resident Room 522, and it was noted that no recent plumbing work had been conducted in that area. Furthermore, the Maintenance Director admitted that while the maintenance staff checked the facility's smoke barrier walls, there was no documentation available for these checks. This lack of documentation and awareness contributed to the failure in maintaining the smoke barrier walls as required by the facility's Smoke Barrier Penetration Policy.
Plan Of Correction
Plan of Correction: Approved December 30, 2024 1. The Unit 5 corridor ceiling penetration next to a steel support beam near Resident Room 519 was sealed by Maintenance. The Unit 5 corridor ceiling penetration located by the corrugated roof deck and the smoke barrier wall above the smoke barrier doors near Resident Room 522 was sealed with a fire rated material by Maintenance Director. The First Floor on Unit 5 penetration near plumbing pipes that were installed through the smoke barrier wall below the sink in the bathroom of Resident Room 522 was sealed with fire rated material by Maintenance Director. 2. All residents are at risk for the deficient practice of smoke barrier walls not being maintained. 3. All smoke barrier walls will be audited for penetrations. Any deficient practice will be repaired. 4. Administrator educated Maintenance Director and Maintenance Tech on Smoke barrier walls and 30 minute resistance rating. 5. The facility will conduct quarterly audits on Smoke barrier walls. Any deficient practices will be repaired and brought to QAPI for further review. Person Responsible: Maintenance Director
Penalty
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