Smoke Barrier Door Deficiency
Summary
The facility failed to ensure that smoke barrier doors were designed to resist fire and smoke in accordance with NFPA 101 standards. During a life safety survey conducted over two days, it was observed that on the first floor, there was a four-inch gap between the door leafs of the smoke barrier doors when tested manually. This deficiency was identified through both observation and an interview with the maintenance director, who acknowledged the issue.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 I. Immediate Corrective Action The doors were adjusted on 4/1/25 and tested to ensure compliance. II. Identification of Other Residents The facility respectfully states that residents could potentially be affected by this deficient practice. The maintenance department split up to inspect all doors in the building. No outstanding issues were noted. III. Systemic Changes The Maintenance department was in-serviced about Smoke Barrier Construction. Maintenance will inspect all areas of service after any construction is completed. IV. QA Monitoring All smoke barriers will be inspected monthly for one quarter. The Director of Maintenance will review all logs on a quarterly basis. This report will be done by the Director of Maintenance or his designee and submitted to the QA committee for review. QAPI committee to determine if further action is required. Responsible Party: Director of Maintenance
Penalty
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