Smoke Doors Failed to Close Smoke Tight
Penalty
Summary
The facility failed to maintain smoke doors in compliance with NFPA 101 standards, specifically affecting one of six floors. During an observation on January 29, 2025, at 10:15 a.m., it was noted that the double corridor smoke doors next to room 443 did not close smoke tight when tested. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director at 11:10 a.m. on the same day.
Plan Of Correction
This provider submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. K0374 The closer was adjusted on the Double corridor smoke doors next to room 443, to allow doors to fully close. Maintenance staff will be educated on smoke barrier doors and the importance for doors to close smoke tight. Maintenance Director will perform monthly audits x3 months of facility smoke doors to ensure doors close smoke tight. Audits will be brought to QAPI Committee for review. QAPI Committee will determine the need for continuance of audits.