Failure to Maintain Fire Resistance Rating in Stairway Enclosures
Summary
The facility failed to maintain the fire resistance rating of stairway enclosures, affecting three of four levels within the building. During a document review and interview on December 16, 2024, it was found that the communicating stairway enclosure did not meet the required one-hour fire-rated construction. This deficiency was due to the presence of wired glass in wooden frames, as well as non-rated doors, frames, and hardware used within the stairway. The condition of the stairway was confirmed during an exit interview with the Administrator and Maintenance Director. A follow-up onsite revisit on February 5, 2025, revealed that the issue had not been resolved, as the stairway enclosure still lacked the necessary fire-rated construction.
Penalty
Stair tower doors on two building levels were found blocked by a caution retractable rope and signage instructing that the stairs were only for emergency use, which could delay resident egress. The maintenance director confirmed this setup during the survey.
A stairtower door near the South Nurses' Station was found not to latch properly because of incorrectly mounted magnet hardware. This deficiency was confirmed by the DON and Director of Maintenance during the survey.
Surveyors found that all rated doors inside a stairwell enclosure between Personal Care and Skilled Nursing failed to positively latch, and a hollow wooden door of unknown fire rating was sealed within a fire-rated wall. These issues were confirmed by facility staff.
An observation revealed that the electronic stairway path interrupter on the 2nd floor egress by the elevators was not functioning, which could cause individuals to miss the correct exit during an emergency. This issue was confirmed with the Maintenance Director and could affect a significant number of residents during a fire.
The facility did not maintain stairtower doors within the allowed gap margins on two floors. Observations revealed that the doors on the 1st and 2nd floors of Stairtower A had gaps exceeding 1/8 inch, confirmed by the Director of Maintenance.
The facility failed to maintain the fire resistance of stairtower enclosures, affecting two smoke compartments. Observations revealed that stairtower doors in specific zones did not positively latch within their frames, as confirmed by the Maintenance Director.
Stairway Exits Blocked by Caution Rope and Signage
Penalty
Summary
During an observation, it was found that stair tower doors on two of five building levels were blocked by a caution retractable rope with signage stating, "STOP!! DO NOT USE STAIRS ONLY FOR EMERGENCY." This setup prevented residents from using the stairways as exits except in emergencies, which could impede their ability to exit promptly. The maintenance director confirmed the presence of the rope and signage at the time of the survey. No additional information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
The systematic change will be to have the retractable rope become a breakaway rope so not to impede progress through the stair tower door. The Director of Maintenance will audit all stairwell doors to assure there a retractable rope in place and report findings to Monthly Quality Assurance meeting.
Stairtower Door Failed to Latch Due to Improper Hardware
Penalty
Summary
A deficiency was identified when the first floor stairtower door, located by the South Nurses' Station, failed to latch properly in its frame. This issue was observed during a facility inspection and was attributed to improperly mounted magnet hardware on the door. The failure of the door to positively latch was confirmed during an interview with the Director of Nursing and the Director of Maintenance at the time of the exit conference. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
1. The first floor stair tower door's hardware was adjusted to ensure positive latch. 2. A facility-wide audit was completed to ensure positive latch of required doors. 3. The Environmental Services Director was re-educated on the requirements of K0225. Monthly door latch audits will occur. 4. The NHA or designee will complete a random audit of facility doors weekly x 4 weeks then monthly x 2 months to ensure positive latch. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.
Failure to Maintain Fire Resistive Rating of Exit Stair Enclosures
Penalty
Summary
Surveyors observed that the facility failed to maintain the fire resistive rating of exit stair tower enclosures across all four levels of the component. On the ground floor, all four rated doors inside the stairwell enclosure leading to the stair tower between Personal Care and Skilled Nursing did not positively latch. Additionally, a hollow wooden door, of unknown fire rating, was found sealed within a door frame set in a cinder block wall inside the stairway enclosure. These findings were confirmed during an exit interview with the Maintenance Supervisor and Director of Safety/Security. No information regarding residents' medical history or condition at the time of the deficiency was provided in the report.
Plan Of Correction
All non-latching doors have been adjusted and doors now latch appropriately. Doors will be monitored during environmental rounds by maintenance staff. The hollow area identified was tested and no door present behind sheetrock. That area consists of two layers of 5/8" sheetrock. Inspection holes were filled with red fire stop caulking to maintain fire barrier.
Inoperative Stairway Path Interrupter on 2nd Floor Egress
Penalty
Summary
During an observation on April 14, 2025, it was found that the electronic stairway path interrupter installed on the 2nd floor stairway path of egress by the elevators was inoperative. This device is intended to guide occupants to the proper egress level during emergencies. The inoperative condition could result in individuals evacuating to the lower level and missing the correct exit during a fire or emergency event with diminished visibility. The deficiency was confirmed at the time of observation with the facility Maintenance Director. A total of 58 out of 175 residents could be affected by this issue in the event of a fire situation, as noted in the findings.
Plan Of Correction
K225- Stairways and Smoke Proof Enclosures 1. The facility has failed to ensure stairways and smokeproof enclosures used as exits are in accordance with 7.2, as required by 19.2.2.3 and 19.2.2.4. 2. The electronic stairway path interrupter installed on the 2nd floor stairway path of egress by the elevators is operative. 3. The maintenance director and staff will be educated on the importance of egress doors/gates being continuously activated and working properly. 4. To ensure continued compliance is maintained with the stairway path interrupter, the Maintenance Director/Designee will complete random audits 5x a week for 4 weeks. Findings will be reported to the QAPI committee. 5. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.
Stairtower Door Gap Deficiency
Penalty
Summary
The facility failed to maintain the stairtower doors within the allowed gap margins on two of three floors. During an observation on April 15, 2025, at 1:20 PM, it was noted that the doors on the 1st and 2nd floors of Stairtower A had gaps greater than 1/8 inch. This was confirmed in an interview with the Director of Maintenance at the same time.
Plan Of Correction
1st and 2nd Floor Stairtower A doors will be corrected to be within the allowed gap margins. Maintenance Staff were educated on Stairways and Smokeproof Enclosures. Stairways used as exits cannot have gaps greater than 1/8 gap. Director of Plant Operations or designee will audit 1 time a month. Audits will be reported at QAPI.
Failure to Maintain Fire Resistance of Stairtower Enclosures
Penalty
Summary
The facility failed to maintain the fire resistance of stairtower enclosures, which affected two of eight smoke compartments. During an observation on April 8, 2025, between 11:11 AM and 11:16 AM, it was noted that the stairtower doors in specific locations did not positively latch within their respective door frames. Specifically, at 11:11 AM, the door in Zone 4, 3rd floor Stair 1, and at 11:16 AM, the door in Zone 3, 3rd floor Stair 2, were found to be deficient. This was confirmed through an interview with the Maintenance Director, who acknowledged that the stairtower doors did not latch properly within the door frames.
Plan Of Correction
1. The zone 4, third floor stair tower 1 door was repaired on 04/11 to ensure that it latches properly. The zone 3, third floor stair tower 2 door was repaired on 04/15 to ensure that it latches properly. 2. Maintenance Director, or designee, will audit weekly for two weeks, then monthly and submit audits to monthly QAPI for review and recommendations. a. A building wide audit of the stair tower doors latching properly was completed. Audits will be done monthly to ensure stair tower doors latch properly.
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