Failure to Maintain Smoke Barrier Doors
Penalty
Summary
The facility failed to maintain, inspect, and test smoke barrier doors as required by regulations. During an observation on February 13, 2025, it was noted that the west wing fire door, specifically the left leaf of the double door, did not latch properly in the frame. This deficiency was confirmed during an interview with the maintenance director on the same day.
Plan Of Correction
Maintenance Director will be educated that fire doors need to latch into the frame when the door closes. Maintenance Director will repair the fire door on the west wing so that it latches into the frame when it closes. Maintenance Director or designee will audit all of the fire doors in the building once a week x 4 weeks and monthly x 4 months to assure that they latch properly when closed.