Smoke Barrier Door Failed to Close Properly
Penalty
Summary
Smoke compartment door #9 did not close to a smoke-tight fit when tested during an observation. The door sweep at the bottom of the door was catching on the floor, which prevented the door from releasing properly and closing as required. The door would not close without staff assistance to move it from the magnetic release. This issue was confirmed by the Facility Maintenance Director at the time of observation. The deficiency could affect 30 occupants in the event of a fire emergency, as the door did not meet the Life Safety Code (LSC) requirements for smoke barrier doors.
Plan Of Correction
K374 1. The Maintenance Director and/or designee will repair the smoke compartment door #9 to ensure it closes properly to prevent the passage of smoke. 2. The Administrator will review regulation K374 and provide education to the Maintenance team on the requirements. 3. The Maintenance Director/designee will conduct a weekly round of smoke compartment doors to ensure they close properly. The Maintenance Director will ensure rounding is logged into the Preventative Maintenance program to ensure continued assessment of function. Results of the audits will be brought to the Quality Assurance Performance Improvement meeting monthly for review. The Committee will be responsible for any changes to the auditing process. 4. The Administrator is responsible to attain and maintain compliance. Completion date for compliance will be 06.20.25.