Deficiency in Fire-Rated Door Frames in Emergency Exit Stairwells
Penalty
Summary
The facility was found to have deficiencies in maintaining vertical openings during a Life Safety Code recertification survey. Specifically, eight emergency exit stairwell door frames across various floors lacked fire-rated labels. These included the first, second, and third-floor south emergency exit stairwells, the second and third-floor northwest emergency exit stairwells, the second and third-floor northeast emergency exit stairwells, and the second-floor center emergency exit stairwell. The absence of fire-rated labels on these door frames was identified during observations conducted on January 13, 2025. The Director of Maintenance was interviewed and revealed that they were unaware of the missing fire-rated labels on the door frames of the emergency exit stairwells. The Director stated that the door frames had been inspected annually by a third party in 2023 and 2024, but the inspection forms did not include a section to document the fire rating of the door frames. The Director acknowledged the requirement for the door frames to have a 1-hour fire-rated label and recognized the importance of this for the safety of residents and staff.
Plan Of Correction
Plan of Correction: Approved February 10, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Ensured vertical openings maintained and fire rating labels placed on the first-floor south emergency exit stairwell, second-floor south emergency exit stairwell, third-floor south emergency exit stairwell, second-floor northwest emergency exit stairwell, third-floor northwest emergency exit stairwell, second-floor northeast emergency exit stairwell, third-floor northeast emergency exit stairwell, and the second-floor center emergency exit stairwell. The facility will identify other residents having the potential to be affected by the same deficient practice and the following corrective action will be taken: - Audit vertical openings and fire rated doors for fire rated labels. The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur: - Education of fire rated doors to have label to door tracking to maintenance staff. The corrective action(s) will be monitored to ensure the deficient practice will not recur: - Audit all fire rated doors for vertical opening and fire rated labels x3 months 100%. The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Director of Maintenance.