Fire Barrier Deficiencies on First Floor
Penalty
Summary
The facility failed to maintain the fire resistance of fire barriers, affecting one of three floors. During an observation on January 30, 2025, between 9:05 a.m. and 9:15 a.m., deficiencies were noted on the first floor regarding common fire wall separations. Specifically, there was an unsealed penetration around data lines above the double doors by the Staff Development Office. Additionally, the double doors by the Staff Development Office failed to close and positively latch when tested, and there was broken hardware on the door. These findings were confirmed during an exit interview with the Administrator and the Maintenance Director on the same day at 11:30 a.m.
Plan Of Correction
Step 1 The maintenance team used 3M fire barrier sealant CP25B+ to seal penetration around data lines above the double door by the staff development office. Hardware on double doors repaired. Doors now positively latch and are closing appropriately. Step 2 The maintenance director/designee completed an audit of all doors to ensure safe operation. Smoke barriers were inspected throughout the building to ensure that there were no other unsealed penetrations. Repairs were completed for any deficiencies found. Step 3 The maintenance team was educated on the requirement to ensure the safe operation of all doors in the facility and to ensure that smoke barrier walls have no unsealed penetration. Step 4 The maintenance director/designee will complete a random audit of doors monthly x 4 to ensure safe operation. Findings will be reviewed during QAPI meeting.