Non-compliance with NFPA 101: Self-Closing Door Devices
Penalty
Summary
The facility failed to maintain doors with self-closing devices in accordance with NFPA 101 standards. During a fire safety tour on April 30, 2025, it was observed that eight out of twenty-nine sampled doors with self-closing devices were not compliant. Specifically, the Beauty Supply Room and the Life Enrichment Dining Room doors were missing door closers. Additionally, several office doors, including those of the Culinary Director, Social Services, Director of Utilization, Physical Therapy, Seaway Wing Office, and Seaway Wing Clinical Services, were held open with magnets that were not connected to the fire alarm system. These deficiencies were identified during a walkthrough with the Plant Operations Technician/Director of Plant Operations, who acknowledged the findings. The issues were discussed with the Administrator and the Director of Plant Operations during the exit conference. Photographic evidence was obtained to support the observations, and the findings were documented as a Class III deficiency under NFPA 101 standards.
Plan Of Correction
No residents were affected by this alleged deficient practice as of 05/16/2025 and none can be identified as of 05/16/2025. The maintenance director and assistants were educated by the Executive Director on 05/16/2025 on K223. 1. The Beauty Supply Room 45-minute fire door, open to the corridor, was repaired and a closer was added on 05/16/2025. 2. The Culinary Director Office door, open to the corridor, had a closer added and the magnet was removed from the door frame on 05/16/2025. 3. The Social Services Office door, open to the corridor, had the magnet removed on 05/16/2025. 4. The Director of Utilization Office door, open to the corridor, had the magnet removed on 05/16/2025. 5. The Physical Therapy door, open to the corridor, had the magnet removed on 05/16/2025. 6. The Seaway Wing Office 90-minute fire rated door, open to the corridor, the magnet was removed on 05/16/2025. 7. The Seaway Wing Clinical Services 45-minute fire rated door, open to the corridor, the magnet was removed on 05/16/2025. 8. The Life Enrichment Dining Room door, open to the corridor, had a door closer installed on 05/16/2025. Doors with self-closing devices will be audited weekly x4 weeks and monthly x6 months. The repair reports and audits will be brought to QAPI on 05/21/2025 for review. No residents were affected by this alleged deficient practice as of 05/16/2025 and none can be identified as of 05/16/2025. The maintenance director and assistants were educated by the Executive Director on 05/16/2025 on K223. 1. The Beauty Supply Room 45-minute fire door, open to the corridor, was repaired and a closer was added on 05/16/2025. 2. The Culinary Director Office door, open to the corridor, had a closer added and the magnet was removed from the door frame on 05/16/2025. 3. The Social Services Office door, open to the corridor, had the magnet removed on 05/16/2025. 4. The Director of Utilization Office door, open to the corridor, had the magnet removed on 05/16/2025. 5. The Physical Therapy door, open to the corridor, had the magnet removed on 05/16/2025. 6. The Seaway Wing Office 90-minute fire rated door, open to the corridor, the magnet was removed on 05/16/2025. 7. The Seaway Wing Clinical Services 45-minute fire rated door, open to the corridor, the magnet was removed on 05/16/2025. 8. The Life Enrichment Dining Room door, open to the corridor, had a door closer installed on 05/16/2025. Doors with self-closing devices will be audited weekly x4 weeks and monthly x6 months. The repair reports and audits will be brought to QAPI on 05/21/2025 for review.