Smoke Barrier Doors Failed to Self-Close and Latch
Penalty
Summary
During an observation on July 30, 2025, at 10:00 a.m., surveyors found that the smoke barrier doors near Room 300 on the third floor did not self-close and latch when tested. This deficiency affected two of seven smoke compartments in the facility. The issue was confirmed in an interview with the Facility Administrator and Maintenance Director later that day. No information regarding residents' medical history or condition at the time of the deficiency was provided in the report.
Plan Of Correction
On July 30, 2025, the Maintenance Director adjusted the smoke barrier doors near room 300 on the third floor to ensure the doors self-close and latch when tested. The Nursing Home Administrator re-educated the Maintenance Director and maintenance assistant on the need to ensure all smoke barrier doors self-close and latch when tested. The Maintenance Director re-tested all smoke barrier doors on all floors to ensure the smoke barrier doors self-close and latch when tested. The smoke barrier doors are already on a weekly testing schedule, but maintenance will increase frequency as needed during seasonal weather changes that may increase/decrease swelling of doors. Results will be submitted to the Safety Committee for review.