Smoke Barrier Door Deficiencies
Penalty
Summary
The facility failed to maintain smoke barrier doors to resist the passage of smoke, affecting one of three levels. During an observation on April 15, 2025, it was noted that a smoke barrier door on the first floor next to room 112 was blocked by a wheelchair, preventing it from closing smoke tight. Additionally, the smoke barrier door in the Chateau Dining area was dragging on the floor, which also prevented it from closing smoke tight. These deficiencies were confirmed during an exit interview with the Administrator, Maintenance Director, and Regional VP of Operations.
Plan Of Correction
1) A. Immediately upon observation on April 15, 2025, the wheelchair next to room 112 was removed so as not to prevent the door from closing smoke tight. B. Chateau Dining the smoke barrier door was repaired so that it does not drag the floor, preventing the door from closing smoke tight. 2) The Maintenance Director and/or designee audited all smoke doors for obstructions and door dragging the floor preventing the door from closing smoke tight. 3) To prevent the potential for reoccurrence, the Administrator and/or designee educated the Maintenance Director and/or designee and staff on the importance of all smoke doors closing smoke tight without obstructions. 4) To monitor and maintain ongoing compliance, the Maintenance Director and/or designee will audit 3 smoke doors for closing smoke tight without obstruction for the next 3 months. If an issue is identified, the Maintenance Director or designee will immediately notify the administrator and correct the problem. Findings will be reported to facility QAPI for continued review and recommendations.