Smoke Barrier Door Deficiency
Penalty
Summary
The facility failed to maintain smoke barrier doors in compliance with NFPA 101 standards, specifically affecting two of eight smoke compartments. During an observation on March 17, 2025, at 10:45 a.m., it was noted that the smoke barrier doors adjacent to the Receiving Room on the first floor had an excessive gap between their meeting edges. This gap compromised the doors' ability to resist the passage of smoke, which is a critical safety requirement. An interview with the Facility Administrator and Maintenance Director later that day confirmed the presence of the excessive gap, acknowledging the deficiency in the smoke barrier doors' functionality.
Plan Of Correction
The Nursing Home Administrator (NHA) provided re-education to the Maintenance Director on 0374 Smoke Barriers. The observed smoke barrier door excessive gap was repaired. The Maintenance Director observed the facility's smoke barrier doors and found no other issues identified. The Maintenance Director/designee will randomly audit the smoke barrier doors weekly x 2 weeks, then monthly to ensure there are no excessive gaps to allow passage of smoke.