Smoke Barrier Doors Failed to Latch and Lacked Self-Closure Devices
Penalty
Summary
Surveyors observed that several smoke barrier doors within the facility did not meet Life Safety Code (LSC) requirements. Specifically, the fire-rated cross corridor door at the 2nd floor storage room with roof access, the fire-rated double door set to Physical Therapy, and the door to the 2nd floor sitting room all failed to positively latch when tested. Additionally, the doors to the Physical Therapy storage area lacked required self-closure devices. These deficiencies were confirmed during the survey through direct observation and interview with the facility Maintenance Director. A total of 58 out of 175 residents could be affected by these issues in the event of a fire, as the doors in question are intended to serve as smoke barriers but did not function as required at the time of inspection.
Plan Of Correction
K374 - Subdivision of Building Spaces - Smoke Barrier 1. The facility failed to ensure smoke barriers doors meet the requirements of the LSC. a. Self-closers have been added to the Physical Therapy Storage doors. b. The fire-rated cross corridor door at the 2nd floor storage room with roof access has been repaired. c. The 2nd Floor Sitting Room door latch has been repaired. d. The latch to Physical Therapy double doors has been repaired. 2. The maintenance director and staff will be educated on the importance of the LSC requirements of various doors in the facility latch properly. 3. To ensure compliance is maintained, the maintenance director/designees will complete random audits 3x a week for 4 weeks. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.