Failure to Maintain Smoke Barrier Doors to Resist Passage of Smoke
Summary
Surveyors found that smoke barrier doors on one of two facility levels were not maintained to resist the passage of smoke as required by NFPA 101. During observation, the smoke barrier doors in the A09 hallway outside the nurse's station did not close smoke-tight when tested because the door frame was unsecured within the wall. In addition, the smoke barrier doors in the A-Wing outside the lobby failed to swing and close smoke-tight due to a broken door closer. These deficiencies were confirmed during interviews with the Administrator and Maintenance Director. On a subsequent onsite revisit survey, surveyors observed that the previously cited issue with the smoke barrier doors in the A-Wing outside the lobby, which failed to swing and close smoke-tight due to a broken door closer, had not been corrected. This uncorrected deficiency was again confirmed with the Administrator and Maintenance Director during the revisit exit interview.
Plan Of Correction
Preparation and /or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed with federal and state law requirements. Identification of other residents or areas having the potential to be affected due to the nature of the deficiency: The deficient practice has the potential to affect all residents. Corrective action 1. Smoke barrier door closures repaired and adjusted to ensure appropriate closure 4/30/26. 2. Maintenance director or designee to re-educate maintenance staff on the importance of maintaining facility smoke barrier doors 3. Maintenance director or designee to audit facility smoke barrier doors to ensure appropriate closure. Weekly X4 monthly X2 4. Maintenance director or designee to audit laundry rooms and medical supply rooms for smoke detectors weekly X4 monthly X2 5. Results will be reviewed at the quarterly QAPI meeting.
Penalty
Smoke barrier doors near the Laundry Area did not fully close when released from hold-open devices, resulting in a failure to maintain smoke-tight conditions as required. Facility leadership confirmed the deficiency during the survey.
Surveyors observed that smoke barrier doors near a third-floor room failed to self-close and latch when tested, affecting two smoke compartments. Facility leadership confirmed the deficiency.
Surveyors observed that the double smoke barrier door between two compartments did not latch as required, with the hardware failing to function per manufacturer specifications. This issue was confirmed by the Director of Facilities and affected two smoke compartments.
Surveyors found that several fire/smoke barrier doors, including those near the DON office and in resident rooms, were unable to close properly during both routine checks and a fire alarm test. Staff confirmed they were unaware of the closure requirements for these doors, resulting in noncompliance with NFPA 101-2012 standards and potentially affecting multiple residents.
Surveyors observed that smoke barrier doors near a resident room and by a nurses station leading to the dining room did not fully close and latch to a smoke-tight fit as required by LSC. The Maintenance Director confirmed these findings.
Surveyors found that smoke barrier doors in three compartments did not release from magnetic holders and close during fire alarm testing, despite activation of smoke detectors, pull stations, and waterflow tests. Staff and a vendor had differing understandings of the door operation, and the malfunction affected all residents in the affected areas.
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.
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.
Smoke Barrier Door Hardware Failed to Latch Properly
Penalty
Summary
During an observation, surveyors found that the double smoke barrier door located between compartments AA and AE did not latch properly when closed. The latching hardware on this smoke barrier door failed to function according to manufacturer specifications. This issue was confirmed in an interview with the Director of Facilities, who acknowledged that the smoke barrier door hardware was not operating as required. The deficiency affected two out of ten smoke compartments within the component. No information regarding residents' medical history or condition at the time of the deficiency was provided in the report.
Plan Of Correction
Hardware will be repaired and adjusted on smoke barrier doors between compartments AA and AE. A recurring work order will be created to inspect doors for proper operation and positive latching quarterly for one year. Completed work order documentation will be presented to QAPI for evaluation.
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.
Smoke Barrier Doors Failed to Achieve Smoke-Tight Fit
Penalty
Summary
The facility failed to ensure that smoke barrier doors met the requirements of the Life Safety Code (LSC). During observations, surveyors found that the smoke barrier doors near room 203 and by the 300 wing nurses station leading into the dining room did not completely close and latch to achieve a smoke-tight fit as required. These deficiencies were confirmed by the Maintenance Director at the time of discovery. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
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
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