Smoke Barrier Doors Failed to Close Smoke-Tight
Penalty
Summary
Surveyors observed that the facility failed to maintain smoke barrier doors in a manner that ensured they were smoke-tight. Specifically, on the ground floor near the Laundry Area, the smoke barrier doors did not fully close when released from their hold-open devices. This deficiency was identified during an observation and was confirmed in an interview with facility leadership, including the Administrator, Regional Director, Regional Maintenance Director, and Environmental Services Director. The report does not mention any residents or specific patient involvement in this deficiency.
Plan Of Correction
The facility failed to maintain smoke barrier doors to be smoke tight, on one of four floors. No residents were affected. All residents have the potential to be affected. The smoke barrier doors, near the Laundry Area on the ground floor, were repaired to close smoke-tight, when released from the hold-open devices. An audit of the facility's remaining smoke barrier doors was completed by the Director of Maintenance to ensure that all smoke barrier doors were smoke-tight when released from the hold-open devices and closed. The Director of Maintenance and maintenance staff were educated by the Administrator on the requirement. The Maintenance Director/Designee will conduct one weekly audit of smoke barrier doors for four weeks, then monthly for two months and then quarterly thereafter. Results of audits will be reviewed at the Quarterly Quality Assurance and Improvement Committee Meeting over the duration of the audit process. Based on the results of the audits, a decision will be made regarding the need for continued submission and reporting.