Failure to Maintain Self-Closing Fire Doors
Penalty
Summary
The facility failed to maintain the rated horizontal fire doors to self-close and positively latch within the frame in four of four smoke compartments. Observations made on December 18, 2024, between 12:05 PM and 12:30 PM, revealed that the horizontal fire-rated doors required springs to be attached to self-close and positively latch in the frame. The specific locations where this deficiency was observed include the 1st floor Kitchen Attic door, the 1st floor outside Kitchen Attic door, the 1st floor by the Activity Room Attic door, and the 1st floor Rainbow Hall by Resident Room 135 Attic door. During an interview at the exit conference with the Administrator and Director of Maintenance, it was confirmed that the horizontal fire-rated doors would not self-close and positively latch.
Plan Of Correction
The facility to inspect the attic doors noted as doors a, b, c, and d to render as non-rated to match the building rating assembly, consistent with the Type V (000) unprotected wood frame structure. The facility will audit all horizontal fire doors to ensure compliance to building structure. The facility to audit attic door compliance quarterly. The findings from the audits will be reported to QAPI for 3 months by maintenance staff.