Unsealed Penetration 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. This deficiency was identified during an observation on January 27, 2025, at 11:20 a.m., where an unsealed penetration was found around data wires above the smoke doors by the Ivy South bathroom. This issue affected two of the six smoke compartments in the facility. The deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 12:30 p.m. The unsealed penetration compromises the integrity of the smoke barrier, which is essential for preventing the spread of smoke in the event of a fire.
Plan Of Correction
by the providers of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared solely as a matter of compliance with federal and state law. The penetration was sealed by the maintenance staff using approved firestop materials. A thorough inspection of the area was completed, and no other penetrations were found. Weekly random inspections, above ceilings throughout WBC, including firewalls, will be conducted by the Maintenance Director/designee for the next 3 months. Results of the inspections will be documented and reported to the Quality Assurance Performance Improvement (QAPI) Steering Committee for further recommendation.