Smoke Barrier Door Deficiency
Penalty
Summary
The facility failed to maintain smoke barrier doors with smoke-tight resistance, as required by NFPA 101 standards. During an observation on January 22, 2025, at 12:30 p.m., it was noted that the double smoke doors on the second floor, West, next to resident room 227, did not close properly. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director later that day at 2:00 p.m. The issue affected two of the three levels in the facility, indicating a lapse in maintaining the required fire safety measures.
Plan Of Correction
Double smoke door near rm 227 is working as designed. It only closes if the fire alarm is activated. Environmental rounds have been conducted through the facility. There were no malfunctioning doors. Maintenance Director or Designee will conduct in servicing for maintenance staff on importance of adherence to: 0374 Subdivision of Building spaces- smoke barriers. The Maintenance team will conduct environmental rounds weekly x 4 weeks to ensure compliance with fire codes, and State, federal and local regulations. Results will be reported in monthly QAPI.