Smoke Barrier Doors Failed to Close During Fire Alarm Testing
Penalty
Summary
During a facility tour and interviews, surveyors observed that the smoke barrier doors adjacent to Rooms 15 and 13, as well as the doors near Rooms 8 and the Dining Room, failed to release from their magnetic door holders and close during fire alarm testing. The testing included activation of a smoke detector, pull station, and waterflow test, but the doors did not respond as required. The doors are intended to close automatically in response to fire alarm system activation to prevent the spread of smoke and fire between compartments. The Maintenance Assistant stated that the doors typically close when only the pull station is tested, but during this inspection, the doors did not function as expected. A sprinkler vendor present at the time believed the doors only close when the sprinkler system is activated. This discrepancy in understanding and the failure of the doors to operate correctly during multiple types of fire alarm activations were directly observed by surveyors. This deficiency affected all 43 residents in the three smoke compartments of the facility. The failure of the smoke barrier doors to close and latch as required by NFPA 101 and related standards was confirmed through direct observation and staff interviews during the survey.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Fire Alarm System vendor was contacted immediately on 05/19/25. Repair to the automatic door releases were completed. A fire watch was instituted during the repair period. Facility was approved to be taken off from fire watch the following day by Life and Safety. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. No residents were found to be affected by this deficient practice. What measures will be put into place or what systemic changes in the facility will make to ensure that the deficient practice does not recur: Maintenance will be doing random tests/checks to ensure proper function. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The Administrator shall report the outcome of the checks/inspections to the Quality Assurance and Assessment Committee (QA&A) during its monthly meeting. If determined that the facility has accomplished the objectives in the plan of correction as aforementioned and the results are successful, then the facility shall consider the matter resolved. The QA&A Committee shall continue to review until such time that the deficiency has been proven to be resolved for 3 consecutive months and/or as advised by the QA&A Committee. Date of Completion of Corrective Action: 05/20/25 How the facility plans to monitor its performance to make sure that solutions are sustained (repeated section): The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The Administrator shall report the outcome of the checks/inspections to the Quality Assurance and Assessment Committee (QA&A) during its monthly meeting. If determined that the facility has accomplished the objectives in the plan of correction as aforementioned and the results are successful, then the facility shall consider the matter resolved. The QA&A Committee shall continue to review until such time that the deficiency has been proven to be resolved for 3 consecutive months and/or as advised by the QA&A Committee. Date of Completion of Corrective Action: 05/20/25