Unsealed Penetrations in Smoke Barriers
Penalty
Summary
The facility failed to maintain the fire resistance of smoke barriers, which is a requirement for ensuring safety in the event of a fire. During an observation on January 22, 2025, unsealed penetrations by data wires were found in the smoke barriers at two locations within the facility. The first unsealed penetration was observed on the second floor near resident room 257 at 10:02 a.m., and the second was on the first floor near resident room 172 at 10:19 a.m. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director on the same day at 10:30 a.m.
Plan Of Correction
Maintenance director was in serviced on checking that all penetrations are properly sealed. Areas identified have been resolved by maintenance director by sealing penetrations around data wires with 3M Fire Barrier Sealant (CP 25WB+). All areas will be reviewed by maintenance director to assure that there are no open penetrations around data wires. Maintenance Director/Designee will monitor all areas to ensure that there are no open penetrations around data wires 3 times per week for 4 weeks and 1 time per month for 2 months. Results will be brought to QAPI and variances will be addressed.