Failure to Maintain Cross Corridor Fire Doors
Penalty
Summary
The facility failed to maintain cross corridor fire doors in accordance with NFPA 80 (2010). During a facility tour with the Maintenance Director, it was observed that the cross corridor fire doors in the 500 Mall did not latch at floor level because the floor latching device, also known as the keeper, was not installed. This deficiency was confirmed during an interview with the Maintenance Director, who acknowledged the absence of the floor latching device and mentioned that corporate staff had advised it was not needed. These findings were verified by both the Maintenance Director and the Administrator during the exit conference.
Plan Of Correction
1. On 3/24/25, a floor latching device was ordered and will be installed upon delivery. The device is anticipated to be delivered and installed by 4/7/25. 2. On 3/25/25, the Maintenance Director observed other facility cross corridor doors to verify that latching devices are in place and functional, and all were found to be in good repair. Current facility residents have the potential to be affected by this deficient practice. Follow up based on findings. 3. On 3/24/25, the Facility Administrator/designee provided education for maintenance employees regarding NFPA 80 cross corridor fire door maintenance and required latching devices. 4. Maintenance Director/designee to monitor cross corridor fire doors to ensure latching devices are in place and functional monthly for 3 months. Findings to be reviewed during the monthly QAPI Committee Meeting. Modifications implemented if indicated.