Fire-Rated Door Deficiency in Smoke Compartment
Penalty
Summary
The facility failed to maintain the integrity of a fire-rated door, which is crucial for ensuring safety in the event of a fire. During an observation, it was noted that the corridor fire-rated door, which separates the Nursing Care area from the Assisted Living area at the breezeway end of the 600 Wing, had been improperly modified. The door had been planed on the strike edge, resulting in gaps greater than 1/8 inch, and a hole in the door had been filled with an unauthorized product. These modifications compromised the door's fire-rating capabilities. The Director of Plant Operations confirmed these deficiencies during an interview conducted at the time of the observation. This issue affected one of the ten smoke compartments within the component, indicating a lapse in maintaining the required fire safety standards as per NFPA 101 guidelines.
Plan Of Correction
This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. It is the practice of the facility to have proper fire rated doors separating Nursing and Assisted Buildings. 1. Replacement of the fire-rated door separating six hundred wings from the assisted living building has been ordered. New fire rated latching hardware will be installed as well. Residents are free from hazards. 2. All rated doors have been inspected, and confirmation of latching and free from gaps completed on 2/7/2025. 3. Education is completed with Maintenance staff to confirm proper door operation of doors on 2/7/2025. 4. Every quarter for a year the Maintenance Director or designee 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.