Deficiency in Smoke-Tight Integrity of Boiler Room Doors
Penalty
Summary
The facility failed to maintain the smoke-tight integrity of hazardous area doors in one of six smoke compartments. During an observation on April 16, 2025, at 11:55 AM, it was noted that there was a gap greater than 1/2-inch between the double doors of the Boiler Room due to a removed astragal. This deficiency was confirmed during an interview with the Assistant Director of Nursing and the Maintenance Director at the exit conference on the same day at 1:45 PM.
Plan Of Correction
1 and 2. Maintenance Director installed astragal between the double doors in the boiler room. 3. Maintenance department will be educated on the standards of ensuring the facility's corridor doors do not have a gap greater than 1/2in. and to not remove astragal. 4. Maintenance or facility designee will audit the facilities corridor doors weekly x2 for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.