Unsealed Penetration in Smoke Barrier Wall
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 28, 2025, at 11:20 a.m., a surveyor identified an unsealed penetration around a sprinkler pipe located above the smoke doors in the phase 2 construction space. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director at 11:45 a.m. on the same day.
Plan Of Correction
Maintenance technician sealed the penetrations around the sprinkler pipe above the smoke doors to phase 2 construction space using UL System C-AJ-1027 stop penetration system on 1/29/2025. All fire door separations in Willowbrooke Court were audited by 2/12/2025 by maintenance technician for penetrations and maintenance of fire rating. The Maintenance Department will be in-serviced by 2/14/2025 the Director of Property Management/Designee on maintaining the fire resistance rating of common walls. The Director of Property Management or designee will conduct random weekly audits x4 weeks to check fire resistance rating of common walls, affecting one of two levels. All findings will be reported to QAPI Committee.