Unsealed Penetrations in Smoke Barrier Walls
Penalty
Summary
The facility failed to maintain the fire resistance rating of smoke barrier partitions, which is a requirement for ensuring safety in the event of a fire. During observations conducted on December 9, 2024, it was noted that there were unsealed penetrations in the smoke barrier walls at several locations on the ground floor. Specifically, these penetrations were found above smoke doors by room W7 around data wires, above smoke doors by room W1 on the storage side around data wires, and above smoke doors by the Director of Nursing's Office around two 3-inch pipes. These observations were confirmed during an exit interview with the Facility Administrator and Maintenance Supervisor.
Plan Of Correction
The facility does and shall continue to ensure common fire walls are maintained free of unsealed penetrations. Pennswood Village Facilities will seal holes and penetrations using through penetration fire stop system C-AJ-8255 products in the following area. Repair shall be made 12/30/2024. The Maintenance Manager/Designee will continue to conduct inspections on a quarterly basis to identify any penetrations of common fire walls and seal them with the required sealant. Results of ongoing inspections will be reported to the Quality Assurance and Performance Improvement (QAPI) Team by the Maintenance Manager/Designee. Pennswood Village Maintenance Manager/Designee will oversee compliance.