Fire-Rated Door Label Illegibility in North Stairwell
Summary
During a Life Safety Code recertification survey, it was observed that the facility failed to maintain the fire-rated door label in the north stairwell. Specifically, the label on the second-floor north stairwell door was painted over, rendering it illegible. This issue was documented in the Swing Door Assembly Inspection Criteria reports from August 2023 and August 2024, which noted the illegibility of the door rating label. On February 11, 2025, at 11:07 AM, the painted-over label was observed, and during an interview on February 14, 2025, the Director of Environmental Services admitted to being unaware of the painted label, despite acknowledging the importance of the label's visibility for resident evacuation and door rating verification.
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 second-floor north stairwell door. Intertek scheduled 4/9/2025 for door repairs. All Maintenance employees received education on Stairways and smokeproof enclosures and identifying if doors are properly rated to protect in the event of a fire. The Director of Environmental Services 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. Audit will be reviewed quarterly with the Quality Assurance and Performance Improvement Committee for 1 year to ensure compliance. Person Responsible: Director of Environmental Services
Penalty
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