Failure of Fire/Smoke Barrier Doors to Close as Required
Penalty
Summary
During a facility tour, surveyors observed that several fire/smoke barrier doors did not function as required by NFPA 101-2012 standards. Specifically, the double corridor fire/smoke barrier door near the Director of Nursing office and a resident room was unable to close. Additionally, fire/smoke barrier doors in two resident rooms failed to close correctly. When the fire alarm system was tested, these doors were also unable to close completely, indicating a persistent issue with the self-closing or automatic-closing mechanisms required for smoke barrier doors. Staff interviews confirmed the findings at the time of discovery. A staff member acknowledged being unaware of the specific requirements for fire/smoke barrier doors as outlined in the NFPA 101-2012 Edition. The observed deficiencies directly contravened the standards, which mandate that such doors must be self-closing or automatic-closing and able to close fully upon activation of the fire alarm or loss of power to the hold-open device. The report also notes a failure to maintain smoking areas in accordance with NFPA 101-2012 Edition, Section 19.7.4. However, the detailed findings and observations related to the smoking area deficiency are not fully included in the provided excerpt. The primary documented deficiency centers on the inability of fire/smoke barrier doors to close as required, potentially affecting 13 out of 46 residents in the facility.
Plan Of Correction
K741 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 7/30/25 as the facility's allegation of compliance date. The facility failed to ensure safe smoking as evidenced by cigarette butts on the ground around staff smoking area, lining the emergency lane parking, yellow line on sidewalk, floor of employee smoking area, in front of storage area that stored combustible materials. Additionally, there were no self-closing metal containers into which ashtrays could be emptied. Step 1: Director of Maintenance cleaned the staff smoking area on 6-6-25. A 16 qt. covered, self-closing, metal receptacle was obtained for placement of cigarette butts and placed in the smoking area on 6/15/25. Step 2: Audit was completed by DON/ADON on designated smoking areas on 6-6-25 for compliance issues, with no negative findings. Step 3: All staff educated on NFPA 101 Smoking Regulations: safe smoking practices and the importance of proper disposal of used smoking materials.