Stairway Door Maintenance Deficiencies
Penalty
Summary
During a Life Safety Code survey, it was observed that stairway doors in the facility were not maintained properly, leading to deficiencies. On the First Floor, the Main Kitchen rear stairway exit door failed to self-close and latch into its door frame due to a missing latch. The door had a significant opening where the latch should have been, and the metal around this opening was bent outward. The Food Service Director and the Maintenance Director indicated that the door had been pried open and broken three months prior. In the Basement, two additional stairway exit doors were found to be deficient. The A Wing stairway exit door did not self-close and latch, and it was noted that this door led to the exterior of the building. An illuminated exit sign was present near the door. The Maintenance Director mentioned that the facility had documentation of checks on the stairway doors. Additionally, the Laundry room rear stairway exit door was observed to not self-close and latch due to a door sweep that caused the door to hang up on the floor of the stairway. The Maintenance Director was uncertain if the door sweep alone was the issue or if the door was also catching on the floor. The facility's Annual Facility Door Audit sheets showed that the stairway doors were checked in September.
Plan Of Correction
Plan of Correction: Approved December 30, 2024 1. Main Kitchen rear stairway exit door had self closing mechanism latch replaced by Maintenance on 1/10/2025. Door was then tested to ensure it self closed and latched in the frame. Basement A Wing stairway exit door had self closing mechanism installed by Maintenance on 1/10/2025. Door was then tested to ensure it self closed and latched in the frame. Basement door by Laundry room rear stairway exit door had self closing mechanism installed and door was repaired by Maintenance on 1/10/2025. Door was then tested to ensure it self closed and latched in the frame. 2. All stairway doors and stairwell areas have potential to be affected by deficient practice of obstruction from closing and latch not working. 3. All facility doors will be inspected to ensure self-closers work properly, and needed repairs to ensure doors close per regulation and latch into frames. 4. The facility’s policy and Life Safety - Means of Egress/ Exits - Hazardous Area Enclosure - Doors with Self Closing Devices, Stairway and Smoke Proof Enclosures policies and audit tool were reviewed and revised to include inspection for penetrations, fire resistance labeling and monthly QA process. 5. Facility Administrator to educate Maintenance Director/Tech on policy and procedure for Means of Egress for self closing devices. 6. A door audit tool will be developed to inspect and identify issues with facility doors including properly working self-closers affixed fire resistance labeling, latching into frame, and without penetrations. - All doors will be audited monthly for 12 months by administrator or designee. - All stairwells will be inspected weekly for 1 month and then monthly for 2 months. - Audit results will be reported to the QA&A Committee monthly for three months. Frequency of on-going audits will be determined by the Committee based on audit results. Person Responsible: Administrator