Failure to Maintain Smoke Barrier Integrity
Penalty
Summary
The facility failed to maintain the fire resistance of smoke barriers, which is a requirement for ensuring safety in the event of a fire. During observations conducted on January 23, 2025, it was noted that the smoke barrier doors on the first floor did not close properly in several locations. Specifically, the doors failed to close together next to the 400 wing at 10:59 a.m., by the entrance to the 500 & 600 wing at 11:12 a.m., and by resident room 605 at 11:21 a.m. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director at 11:45 a.m. on the same day.
Plan Of Correction
1. The smoke barriers doors have been adjusted to ensure they positively latch in the following areas: next to 400 wing, entrance of 500 & 600, and by resident room 605. 2. The Director of maintenance was educated on the requirement for smoke barrier doors to positively latch. 3. Maintenance Director/Designee completed an audit of smoke barrier doors in the facility to ensure they positively latch. 4. Maintenance Director/Designee will conduct a random audit of smoke barrier doors to ensure they positively latch. The audit will be completed weekly x4, then monthly x2. Report of audit will be reported at monthly QA.