Deficiency in Stairwell Fire Resistance Rating
Penalty
Summary
The facility failed to maintain the fire resistance rating of stairwells as required by the NFPA 101 Life Safety Code. During an observation, a door opening into a five-story stairwell was found to lack the necessary latching fire exit hardware. Instead, the door was secured closed by a magnetic locking device. This deficiency was identified during an observation and interview, where it was confirmed that the facility was unaware of the requirement for latching hardware to secure the door in the frame. The magnetic locking device was designed to release upon activation of the fire alarm, allowing the door to swing freely into the exit stairwell. This issue had the potential to affect 40 residents.
Plan Of Correction
The proper latching fire exit hardware was installed on the stairwell lower-level annex door. All residents have the potential to be affected. The Maintenance Director audited all stairwell exit doors to assure they had a proper latching fire exit hardware. All other stairwell doors were found with proper latching hardware. The Maintenance Director will make monthly rounds to ensure the proper latching fire exit hardware is installed on all doors. The Maintenance Director will report the results of these audits to the Administrator on a monthly basis. The Maintenance Director will review the findings of the monthly audits at the Quarterly QAPI Meeting for the next 2 quarters.