Smoke Barrier Doors Not Closing Smoke Tight
Penalty
Summary
The facility failed to maintain smoke barrier doors on one of its five floors, as observed during a survey. On December 12, 2024, at 10:12 a.m., it was noted that the smoke barrier doors in the East corridor did not close smoke tight, which is a requirement for ensuring proper smoke containment. This deficiency was confirmed during an exit conference on the same day at 11:45 a.m. with the facility's administrator, maintenance representative, and regional facility representative, who acknowledged that the doors did not fit together smoke tight.
Plan Of Correction
The east corridor smoke barrier doors were fixed to close smoke tight. NHA educated the Maintenance Director on maintaining smoke barrier doors. An initial audit was completed to ensure smoke tightness of all smoke barrier doors. NHA/designee will audit weekly x 4, then monthly x 3.