Smoke Barrier Doors Not Properly Maintained
Summary
During a Life Safety Code survey, it was observed that the smoke barrier doors on the first floor of the Evergreen Unit did not close properly, leaving a gap greater than one quarter inch between them. This gap compromised the doors' ability to prevent the passage of smoke, affecting one of the two resident use floors. The Maintenance Supervisor confirmed that the facility's maintenance staff conducted monthly checks on the smoke barrier doors, as documented in the Security Door Checks logs from February 2023 through January 2025. However, these logs did not record any issues regarding the gap between the doors, indicating a failure to identify and address the deficiency during routine inspections.
Plan Of Correction
Plan of Correction: Approved February 26, 2025 The unit smoke barrier doors found during survey not close the opening between them, leaving more than the minimum clearance necessary to prevent the passage of smoke have been repaired with vertical door seals to assure they meet life safety code standards. An audit of all facility smoke barrier double-doors will be completed to assure they do not contain vertical gaps that would allow passage of smoke. Any areas identified as not properly closing and allowing an opening between them will be repaired per life safety code standards. A review of the facilities policy related to door inspections will be completed to assure it contains language that outlines the procedures for proper inspection to include closing, latching, and not having a gap in the opening between them if they are double doors. The audit documents used for door inspections will also include the language specific to the procedure. All maintenance staff will receive education and in-servicing on this new policy and procedure. Random audits of smoke barrier doors will be completed monthly, as part of the security door check audits, for three months to assure ongoing compliance. These audit results will be placed on the agenda of the Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Director of Maintenance will be responsible for ongoing compliance with these corrective measures.
Penalty
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