Smoke Barrier Door Deficiency
Penalty
Summary
The facility failed to maintain smoke barrier doors in compliance with NFPA 101 standards, specifically affecting two of the 15 smoke compartments. During an observation on January 23, 2025, at 10:40 a.m., it was noted that the smoke barrier doors in the South Wing hallway had an excessive gap between their meeting edges. This gap was significant enough to prevent the doors from effectively resisting the passage of smoke. An interview conducted with the Facility Administrator and Maintenance Director later that day at 1:30 p.m. confirmed the presence of the excessive gap in the smoke barrier doors, which compromised their ability to resist smoke passage.
Plan Of Correction
1. Facility maintenance contacted the vendor that installed the 1st floor south fire doors. The vendor made repairs to the doors on January 31st, 2025, eliminating the excessive gap between the meeting edges of the doors. 2. The maintenance director or designee will perform a one-time inspection of the facility to ensure fire doors do not have excessive gaps between the meeting edges of the doors on or before March 14, 2025. 3. Results of the audit will be reviewed in QA.