Unsealed Penetrations in Smoke Barrier Walls
Penalty
Summary
The facility failed to maintain smoke barrier walls free of unsealed penetrations, which is a requirement for ensuring a 1/2-hour fire resistance rating. During an observation on January 22, 2025, at 12:55 p.m., it was noted that on the second floor, above the smoke doors near resident room 253, there were unsealed penetrations around data wires. This deficiency affected two of the four smoke compartments in the facility. The issue was confirmed during an exit interview with the Facility Administrator and Maintenance Director on the same day at 2:00 p.m.
Plan Of Correction
The unsealed penetrations near 253 have been sealed with an approved through-penetration fire sealant. Environmental rounds have been conducted through the facility. There were no further penetrations. The Maintenance Director or Designee will conduct in servicing for maintenance staff on the importance of adherence to 0372 Subdivision of Building spaces - Smoke Barrier. The interdisciplinary team will conduct environmental rounds weekly x 4 weeks to ensure compliance with fire codes, and State, federal and local regulations. Results will be reported on monthly QAPI.