Deficient Fire-Rated Door Compliance in Hazardous Areas
Penalty
Summary
The facility failed to ensure that fire-rated doors to hazardous areas were self-closing, properly labeled, and separated by smoke-resisting partitions as required by NFPA 101, 2012 Edition. This deficiency was observed in two of six doors located at the back of the facility, potentially affecting 25 residents in the identified area. Specifically, an observation at 10:10 AM revealed that the set of wooden doors to the kitchen had a gap of approximately 1/2-inch to 3/4-inch when in the closed position, compromising the fire barrier's integrity. Additionally, at 10:21 AM, it was observed that the blue door from the kitchen to the resident dining room would not fully close and latch due to positive air pressure from the kitchen, causing the door to remain open by approximately 6 inches. These observations were confirmed in an interview with the involved staff members. The deficiency was communicated to the facility during the Life Safety Code exit conference.
Plan Of Correction
K-0321 (E) NFPA 101- Hazardous Areas Enclosure 1. Replacement of kitchen-rated doors were ordered on January 14, 2025 with installation prior to compliance date of February 11, 2025. New fire rated latching hardware will be installed as well. Residents are free from hazards. 2. All hazardous enclosure doors have been inspected, and confirmation of latching and free from gaps completed on 1/10/2025. 3. Education is completed with Maintenance staff to confirm proper door operation of doors on 1/10/2025. 4. Every quarter for a year the Maintenance Director or designee will review random doors throughout the building for proper operations. This information will then be entered on a log and will be presented to the QAPI meeting quarterly for one year. * See attached quote and receipt of payment for kitchen rated doors* * See attached photo of kitchen double door replacement*