Smoke Barrier Doors Not Properly Sealed
Penalty
Summary
During an observation on May 8, 2024, surveyors identified that the smoke barrier doors located at the 100/200 hall did not meet the required standards set by the Life Safety Code (LSC) 19.3.7.8 and 8.5.4. Specifically, when the doors were in the closed position, there was an opening of more than 1/8 of an inch between the door leafs. This noncompliance was confirmed through an interview with the facility Maintenance Director at the time of the observation. The deficiency could potentially affect 23 occupants within the smoke compartment if smoke were to pass through the barrier doors during a fire in the adjoining compartment.
Plan Of Correction
The smoke barrier doors located at 100/200 hall had an astragal installed by the Maintenance Director on 5-21-25 to eliminate the gap between the leafs. A one-time audit was completed by the Maintenance Director on 5-20-25 to ensure all double smoke barrier doors did not have anything over an 1/8 gap between the leafs. Education was provided to the Maintenance Director on 5-20-25 to the requirements of having smoke barrier doors come to a seal to prevent the passage of smoke. A monthly audit x3 will be completed by the Maintenance Director or designee to ensure that there are not any gaps in the double smoke barrier doors. Audit findings will be presented to the facility QAPI committee and will only be discontinued with substantial compliance and with approval of the facility QAPI. The Administrator is responsible for achieving and sustaining compliance.