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K0374
E

Failure to Maintain Smoke Barrier Doors

Selinsgrove, Pennsylvania Survey Completed on 02-03-2025

Penalty

No penalty information released
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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 smoke barrier doors in compliance with NFPA 101 standards, affecting multiple areas within the building. During an observation on February 3, 2025, at 11:29 am, it was noted that the smoke barrier doors at the top of the ramp near the exit did not fully close when released from the hold open devices. This issue was confirmed during an interview with the administrator and maintenance representative at the exit conference on the same day, indicating that the doors did not close smoke tight as required. Additionally, another deficiency was observed on the same day at 11:07 am on the 1st floor, where the right leaf of the smoke barrier doors near the employee lounge failed to completely close and latch when released from the hold open devices. This was also confirmed during the exit conference interview with the administrator and maintenance representative. These deficiencies indicate a failure to maintain the smoke barrier doors in a manner that ensures they function properly to resist fire and smoke, as required by the NFPA 101 standards.

Plan Of Correction

1. The smoke barrier door at the top of the ramp that failed to close when tested will be repaired to proper function. 2. Additional smoke barrier doors will be reviewed for proper function. 3. The Executive Director/ designee will educate the Maintenance Director on the importance of maintaining smoke barrier doors to proper function in accordance with NFPA standards. 4. Any findings will be reported to the monthly QAPI Committee for further review. 1. The smoke barrier door near the employee lounge that failed to latch will be repaired to proper function. 2. Additional smoke barrier doors will be reviewed for proper function. 3. The Executive Director/ designee will educate the Maintenance Director on the importance of maintaining smoke barrier doors for proper function in accordance with NFPA standards. 4. Any findings will be reported to the monthly QAPI Committee for further review.

See complete original report
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