Smoke Barrier Door Fails to Close Properly
Penalty
Summary
During a Life Safety Code survey, it was observed that a smoke barrier door on the second floor of the facility did not fully close. The door, located across from a resident room, was found to be hung up on its door frame. Maintenance Staff #2 mentioned that the door had been checked in the past but could not confirm if it was checked recently. The Executive Director of Environmental Services noted that the screws were loose and the door required adjustment to close properly. They also believed the door was part of a smoke barrier wall, but were unable to confirm this due to the absence of architectural drawings. A review of the facility's undated floor plan indicated that the door was indeed located along a smoke barrier wall.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Action: Following the observation of the lavatory across from resident room [ROOM NUMBER] not fully closing, due to the door being hung up on its door frame. Maintenance immediately fixed the lavatory door to ensure proper closure. Identify Other Residents: All residents have the potential to be affected by this deficient practice. No other residents were identified as being affected by this deficient practice. All doors identified within the smoke barriers walls were inspected, with no negative findings. Systemic Changes: All maintenance staff to be re-educated by the Facilities Director or designee re-educated on the proper closing and latching of smoke barrier doors. The Director of Maintenance or Designee will create a new audit tool that will be utilized to perform bi-monthly audits of smoke barrier doors for 6 months. Monitor Corrective Actions: Director of Facilities to report the results of the bi-monthly audits at the monthly QAPI Committee. The QAPI Committee is responsible for the ongoing monitoring and compliance. Person Responsible for Implementation: The Director of Facilities.