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 30, 2025, at 9:30 a.m., it was noted that on the first floor South, above the smoke doors by room 142, there was an unsealed penetration around a data wire. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director on the same day at 11:30 a.m.
Plan Of Correction
Step 1 The maintenance team used 3M fire barrier sealant CP25B+ to seal penetration around data lines above the smoke doors by room 142. Step 2 Smoke barrier walls were inspected throughout the building to ensure that there was no other unsealed penetration. Repairs completed for any deficiencies found. Step 3 The maintenance team was educated on the requirement to ensure that there is no unsealed penetration around the data line on smoke barrier walls. Step 4 The maintenance director/ designee will complete a random audit of smoke barrier walls monthly x 4. Findings will be reviewed during the QAPI meeting.
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