Smoke Barrier Doors Failed to Close Smoke Tight
Penalty
Summary
The facility failed to maintain smoke barrier doors to resist the passage of smoke, as required by NFPA 101 standards. During an observation on January 27, 2025, at 1:20 p.m., it was noted that the smoke doors located on the second floor by room 203 did not close smoke tight when tested. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director at 2:30 p.m. on the same day, indicating a failure to meet the necessary fire safety requirements for smoke barriers.
Plan Of Correction
1. The smoke doors near room 203 were immediately scheduled for maintenance to ensure they close smoke-tight. 2. Smoke doors throughout the facility audited to ensure they close smoke-tight. 3. Education will be provided to ensure proper compliance with this regulation. 4. An audit of three smoke doors will be conducted to ensure they are in proper working order. Audit will be done 2x a month for 2 months and 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.