Fire Door and Egress Deficiencies
Penalty
Summary
The facility failed to maintain the means of egress free of obstructions or impediments, as required by the Life Safety Code. During the survey, it was observed that multiple fire doors were not properly maintained, and a tripping hazard was present at one direct exit. Specifically, the fire doors in the boiler room, kitchen main door, and kitchen doors leading to the dining room had illegible or missing fire ratings. Additionally, the clean linen door, evening maintenance closet, and kitchen dry storage room lacked documentation of fire door ratings. Observations included a non-fire-rated door in the new office side, fire doors held open by magnetic holders not connected to the fire alarm system, and linoleum curling up in front of the North Stairwell exit door, creating a tripping hazard. Further deficiencies were noted with the boiler room door assembly having its fire ratings painted over, and the kitchen door from the service hallway having an illegible fire rating. The kitchen double doors had their fire-rated labels painted over and did not close and latch properly when tested. During an interview, the Director of Environmental Services acknowledged being unaware of all the doors identified during the survey but confirmed awareness of several doors with painted fire-rated labels. The importance of maintaining clear exits and properly rated doors for evacuation and fire protection was emphasized.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Quote has been requested by Director of Facilities from an outside vendor known as Intertek, which specializes in inspecting fire and egress door assemblies to the NFPA 80 Standard. The quote will include affected boiler room, kitchen main door, kitchen doors going to dining room, clean linen door, evening maintenance closet, and the kitchen dry storage room for either re-certification and/or replacement. Intertek scheduled to be onsite for door repairs 4/9/2025. The Magnetic holders were removed from the fire doors that connect two offices to the building. A threshold was placed over the curled linoleum in the north stairwell. All Maintenance Employees were educated on maintaining clear means of egress continuously and properly maintaining fire doors. The Director of Environmental Services or designee will audit the doors monthly to ensure they are still fire-rated with legible tag, and no doors are held open by magnetic holder, unauthorized door [MEDICATION NAME], or floor obstructions blocking egress. The Audit will be reviewed quarterly with the Quality Assurance and Performance Improvement Committee for 1 year to ensure compliance. Person Responsible for Completion: Director of Environmental Services