Smoke Barrier Door Deficiency
Penalty
Summary
The facility failed to maintain doors in smoke barrier walls to resist the passage of smoke, as required by NFPA 101 standards. During an observation conducted on December 30, 2024, between 10:45 a.m. and 12:00 p.m., it was noted that one of the double smoke doors located next to the nurses' station had two hole penetrations through both sides of the door, above the door closer. This deficiency was confirmed during an interview with the Executive Director at the exit conference on the same day at 12:00 p.m.
Plan Of Correction
The penetrations were repaired using approved fireproof caulk. The Facility Director will inspect and audit all fire doors to ensure there are no penetrations. Audits will be conducted at the time of repair and then quarterly thereafter.