Fire Door Labeling Deficiency
Penalty
Summary
The facility failed to maintain fire doors in accordance with NFPA 101 and NFPA 80 standards. During a Life Safety survey, it was observed that the fire-rated labels on several fire doors were either covered with paint or illegible. This issue was identified in the basement and on one of the two resident floors. Specifically, the fire-rated label on the center stairwell door in the basement was covered with paint, as were the labels on the fire door to the soiled utility room, the storage room in corridor D, the stairwell door in Corridor 3, and the door to the clean linen room on the B even side. The Director of Maintenance acknowledged the issue during an interview at the time of the finding.
Plan Of Correction
Plan of Correction: Approved April 11, 2025 K761 I. Immediate Corrective Action: 1. Fire Door Labels Covered with Paint/Illegible: - On 3/19/25, the Director of Maintenance conducted an immediate inspection of all fire doors with illegible or covered fire-rated labels. - The paint was removed from the labels on the center stairwell door, soiled utility room door, storage room door in corridor D, stairwell door in corridor 3, and the clean linen room door on the B even side by 3/20/25. All of the above referenced fire rated labels are now legible. II. Identification of Others: - All residents have the potential to be affected. - A thorough inspection of all fire doors within the facility was conducted to ensure no other fire-rated labels were covered or illegible. - No other issues were found, but the Director of Maintenance has implemented a regular inspection schedule for fire doors to prevent the recurrence of this issue. III. Systemic Changes: 1. The Director of Maintenance reviewed the facility's policy on fire door maintenance to ensure that all fire-rated labels are always clearly visible and legible. 2. The Director of Maintenance in-serviced all maintenance staff on the importance of maintaining clear and legible fire-rated labels and ensuring fire doors remain in compliance with NFPA 101 and NFPA 80. IV. Quality Assurance: 1. The Director of Maintenance created an audit tool to track the status of fire door label visibility. - Monthly audits will be conducted for six months with findings reviewed to ensure that all fire door labels are visible and legible. 2. The results of monthly audits will be reported to QAPI quarterly. V. Person Responsible: - Director of Maintenance