Smoke Barrier Door Deficiency on Fifth Floor
Penalty
Summary
The facility failed to maintain the smoke barrier separation doors on the fifth floor, specifically the Clay Street smoke barrier doors. During an observation on January 7, 2025, at 11:07 a.m., it was noted that these doors required adjustment to fully latch. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager later that day, between 12:15 p.m. and 12:20 p.m.
Plan Of Correction
Observation 1: Observation revealed the fifth floor, Clay Street smoke barrier separation doors required adjustment to fully latch. 1) What systematic changes will be put into place to ensure that the deficiency does not recur, and how the corrective action(s) will be monitored: The Smoke Barrier Separation Door was adjusted to fully closed by the Assistant Director of Maintenance. All Barrier separation doors will be inspected to ensure proper closing during all fire drills by the members of our Maintenance team on their assigned floors during the fire drills. Barrier Separation door inspections will be submitted to QAPI Committee Quarterly by the Director of Maintenance and presented for review/discussion.