Smoke Barrier Door Deficiency
Penalty
Summary
The facility failed to meet the smoke barrier requirements on one of its three building levels. During an observation conducted on March 11, 2025, between 11:00 a.m. and 11:24 a.m., it was noted that the smoke barrier doors had large gaps that would allow air flow, compromising their effectiveness. Specifically, the smoke barrier doors next to the administration office and those next to room 430 were identified as having these deficiencies. An interview with the maintenance supervisor at 11:24 a.m. on the same day confirmed the presence of these deficiencies at the time of the survey.
Plan Of Correction
Work order # 192928 added to our computerized work order system to replace the astragals of smoke barrier doors between West and Lake halls on our Skilled Nursing Unit limiting the gap of the doors to 1/8 of an inch or less. The astragal have been replaced and will be monitored monthly for 4 months and reported at our quarterly QAPI meeting.