Smoke Barrier Door Deficiency on Third Floor
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to maintain the smoke resistance of smoke barrier doors on the third floor, as observed during a survey. Specifically, there were holes found in the door frame, which compromised the smoke resistance of the doors. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director.
Plan Of Correction
Holes in the door frame on the third floor were repaired. Maintenance to be educated on maintaining the smoke resistance of smoke barrier doors. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee.