Vertical Opening Fire Safety Deficiency
Penalty
Summary
The facility failed to maintain proper fire safety measures for a vertical opening between two floors. During an observation on December 23, 2024, it was noted that the self-closing devices had been removed from the double doors of the Private Dining Room. These doors are part of a one-hour, two-story vertical opening, which is required to have a fire resistance rating of at least one hour. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager.
Plan Of Correction
Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. The plan of correction is prepared and executed as a means to continually improve quality of care and to comply with all applicable state and federal regulatory requirements. Door closer has been installed on the Private Dining Room door. Door closers throughout the facility have been audited and are working properly. NHA/Designee educated the Maintenance Director on NFPA 101 Hazardous Areas-Enclosures. Maintenance Director will randomly audit door closures 1x week for 4 weeks then monthly x2.