Corridor Doors Not Smoke-Resistant
Penalty
Summary
The facility failed to ensure that all corridor doors were designed to resist the passage of smoke, as required by the 2012 NFPA standards. During a life safety survey conducted on two consecutive days, it was observed that one panel of the double doors to the Electrical Closet had a manual bolt, which prevented the doors from latching properly and resisting the passage of smoke. This deficiency was found on all five resident floors of the facility. The Director of Maintenance acknowledged the issue and indicated that the manual bolts would be replaced with automatic flush bolts.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The facility contacted the construction vendor on 2/27/25 to remove the manual flush bolt from the inactive leaf on the identified room doors and will permanently install automatic flush mount bolts on the inactive corridor doors to provide positive latching. Automatic flush mounts bolts has been ordered on [DATE]. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility acknowledges that all residents have the potential to be affected by this practice. The Director of maintenance inspected all areas throughout the facility for the same deficiency. No deficiencies found. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: The facility reviewed the Fire and Smoke Door policy and procedure. The policy was updated to include Corridor doors shall comply with 2012 NFPA 101: 19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction. Double doors shall be equipped with auto flush mount bolts. Manual flush mount bolts are prohibited. The Maintenance staff will receive education on the Fire and Smoke Door policy and procedures. An audit tool was developed to check corridor doors equipped with auto flush mount bolts. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a weekly basis, for one quarter, the Dir. Maintenance or designee will audit all Double doors to for auto flush mount bolts to ensure compliance. Any outstanding issues will be addressed immediately and reported to the Administrator. On a monthly basis, The Director of Maintenance or Designee will review monthly audits and report findings to Administrator. On a quarterly basis, The Director of Maintenance or Designee will report the result of the audits to the QAPI. 5. The title of the person responsible for correction of each deficiency: Administrator, Director of Maintenance.