Smoke Barrier Doors Not Maintained
Penalty
Summary
The facility failed to maintain smoke barrier doors in accordance with NFPA 101 standards, as observed during a Life Safety recertification survey. Specifically, the smoke barrier doors in two of the three resident buildings, namely the Weinberg Pavilion and the NH building, were unable to resist the passage of smoke due to an opening between the two sets of doors. This deficiency was identified during the survey conducted on January 30 and 31, 2025. During an interview on January 30, 2025, the Director of Plant Operations acknowledged the issue, stating that the doors are checked monthly and will be adjusted to close properly.
Plan Of Correction
Plan of Correction: Approved February 28, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is The maintenance staff will install fire rated door extensions to permanently reduce the center gap opening to less than 1/8” to the identified smoke barrier doors in the Weinberg and Nursing Home buildings. 2. How will The New Jewish Home (NAME) Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above)? The facility acknowledges that all residents have the potential to be affected by this practice. The Director of Maintenance inspected all areas throughout the facility for same deficiencies. No other deficiencies were identified. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur? All maintenance staff will receive additional education and all participants will understand the life safety issues identified, smoke barrier doors. The Director of Maintenance has been assigned the responsibility for the education of staff and report the findings to the QAPI Committee for the period of six (6) months. The facility will check that all smoke barrier doors will prevent the passage of smoke monthly. The Director of Maintenance will complete documentation in an audit tool and report the findings to the QAPI Committee monthly for a period of six (6) months. 4. How will The New Jewish Home (NAME) Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor the continued effectiveness of the systemic change)? The Director of Maintenance or Designee will review monthly audits for any cases of non-compliance. The Director of Maintenance or Designee will report the result of these audits to the QAPI committee on a monthly basis, as well as correction plan if warranted.