Unsealed Penetration in Smoke Barrier
Penalty
Summary
The facility failed to maintain smoke barrier walls, which is a requirement for ensuring fire safety. During an observation on January 30, 2025, at 9:50 a.m., an unsealed penetration was found above the double doors leading from the loading dock into the laundry department. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 12:45 p.m. The unsealed penetration compromises the smoke barrier's integrity, which is essential for maintaining a 1/2-hour fire resistance rating as per NFPA 101 standards.
Plan Of Correction
Maintenance to seal penetration above double doors from loading dock into laundry department with an approved UL listed fire stop barrier system. Maintenance director or designee to conduct monthly inspections of penetrations. The Maintenance Director or designee will report monthly findings to Quality Assurance for a 90-day period.