Failure to Maintain Smoke Barrier Doors
Penalty
Summary
The facility failed to maintain smoke doors in compliance with NFPA 101 standards, affecting multiple areas across different floors. On February 3, 2025, observations revealed that the double doors to the Day Room on the first floor, next to rooms 129 and 118, did not close smoke tight when tested. Additionally, on the same day, the double smoke barrier doors next to the elevator on the first floor were found to have missing hardware on the push bar. These deficiencies were confirmed during an exit interview with the Maintenance Director on February 4, 2025. Further observations on February 4, 2025, indicated that on the second floor, next to room 208, one of the double smoke doors was obstructed by a bariatric chair, preventing it from closing smoke tight. This condition was also confirmed during the exit interview with the Maintenance Director. These findings demonstrate a failure to ensure that smoke barrier doors were maintained to resist the passage of smoke, as required by the NFPA 101 standards.
Plan Of Correction
Plan of Correction: Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0374 A & B A. New door coordinator for double doors next to room 129 will be installed. Door will be monitored monthly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. B. New door coordinator for double doors next to room 118 will be installed. Door will be monitored monthly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0374 Missing Hardware on push bar was installed on door. Door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. 2/19/2025 Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. Chair was removed from area blocking fire doors. Door was checked to ensure smoke tight closure. Fire and Safety or designee will monitor area weekly for 1 quarter to ensure this issue does not reoccur.