Unsealed Penetrations in Smoke Barrier Walls
Penalty
Summary
The facility failed to maintain smoke barrier walls free of unsealed penetrations, as required by NFPA 101 standards. During an observation on December 18, 2024, at 12:15 p.m., it was noted that there were unsealed penetrations above the smoke barrier doors next to room 110. This issue arose due to the installation of a newly run data line, which compromised the integrity of the smoke barrier. The deficiency was confirmed during an exit interview with the Administrator, Administrator in training, and the Director of Maintenance on the same day at 1:45 p.m.
Plan Of Correction
Fire caulk has been used to fill in the opening created by the installation of the data line. Maintenance will check smoke barriers on a routine monthly basis and document findings in the Maintenance Audit Book. All penetrations have been and will be corrected moving forward using a UL approved stop gap penetration system.