Corridor Doors Not Smoke-Resistant
Penalty
Summary
The facility failed to ensure that all corridor doors were maintained to resist the passage of smoke, as required by safety regulations. During a life safety survey conducted on February 10, 2025, it was observed that transfer grilles were present on corridor doors across multiple floors, specifically on floors 1 through 4. These grilles were found on the doors to janitor's closets near rooms 4C25 and 4D08 on the 4th floor, near rooms 3A08, 3D08, and 3B25 on the 3rd floor, near rooms C25 and D08 on the 2nd floor, and on the utility room door near the activities room on the 1st floor. The presence of these grilles violates the requirement that corridor doors must be constructed to resist the passage of smoke, as outlined in the 2012 NFPA 101 and 2011 NFPA 25 standards, as well as 10 NYCRR 711.2 (a).
Plan Of Correction
Plan of Correction: Approved February 24, 2025 I. Immediate Corrective Action The transfer grilles which were found on corridor doors in the following locations were closed off with metal plates: 1) On the doors to the janitor's closets near rooms 4C25 and 4 DO8 on the 4th floor. 2) On the 3rd floor janitor's closets near rooms 3A08, 3D08 and 3B25. 3) On the 2nd floor near rooms 2C25 and 2D08. 4) On the 1st floor on the utility room near the activities room. II. Identification of Other Residents a. An audit has been conducted of all corridor doors throughout the facility to make sure all doors close and latch as required with proper sealing to prevent the transfer of smoke. b. No additional doors were found noncompliant. c. No residents' additional residents were found to be affected upon completion of this review. III. Systemic Changes 1. The facility has reviewed the Preventive Maintenance Plan and door inspection policy and revised the same to include directives for ventilation grilles, as well as inspection observations. 2. All Maintenance staff will be educated by the maintenance director on the Preventive Maintenance Plan and requirement for appropriate Door operation. 3. The Lesson Plan will concentrate on the following: > Overview of requirements for K363 > Preventive Maintenance plan for performing observational inspections of the doors > Responsibility for providing appropriate door closures. 4. A copy of the Lesson Plan and attendance will be filed for reference and validation. a. The facility reviewed and revised its policy regarding corridor doors. b. All maintenance staff were in service on the updated corridor door policies. IV. QA monitoring a. An audit tool was created to monitor the facility’s corridor doors. b. Monitoring of the facility’s doors shall be performed monthly for the first 3 months and then quarterly thereafter for 9 months. c. Any negative findings from inspections shall be reported to the administrator for further evaluation and will be addressed. d. All reports shall be brought to the Quality Assurance meeting to review with the team to ensure that repairs are being performed in a timely manner for 12 months. V. Title Responsible Director of maintenance