Smoke Barrier Door Deficiencies
Penalty
Summary
The facility failed to maintain smoke barrier doors in accordance with NFPA 101 (Life Safety Code) 2012 Edition, Section 8.5, which had the potential to affect 42 residents. During an observation, a smoke barrier door located in the corridor by Room 104 did not close smoke tight when released from the magnetic hold open device, stopping halfway between the open and closed position. The facility staff confirmed the door was rubbing the floor and was unaware of this issue prior to the survey. Additionally, another observation revealed that a smoke door located in the bathroom between Rooms 210 and 211 lacked a self-closing device. The facility staff confirmed the absence of the self-closing device and stated they were unaware of this deficiency before the survey.
Plan Of Correction
Element 1 This deficiency was corrected by preventing the door from rubbing against the floor in the corridor near room 104, allowing the smoke barrier door to fully close and latch. Additionally, a self-closing device was installed on the bathroom door between rooms 210 and 211. Element 2 This deficiency has the potential to affect forty-two residents on the East Wing. Element 3 A Smoke Barrier Door audit is being conducted by the Maintenance Director or designee to ensure the facility remains in compliance with K374. This audit will be completed by making rounds within the facility. Element 4 The Smoke Barrier Door audit is being monitored by the Administrator or designee once a week for two months, then once every other week for two months, and then once a month for two months. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.