Unsealed Penetration in Smoke Barrier Wall
Penalty
Summary
The facility failed to maintain smoke barrier walls free of unsealed penetrations, as required by NFPA 101 standards. During an observation on the second floor above the double doors near the Rehabilitation Department, an unsealed penetration was found around data wires. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director. The issue affected one of two floors in the building. No information regarding residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
Unsealed penetration data wires around double doors by Rehabilitation office were sealed with fire stop compound. The maintenance director/designee will perform weekly safety rounds to ensure there are no ceiling penetrations that need to be sealed. Maintenance director/designee will report on the corrective action monthly x 6 months during QAPI.