Failure to Maintain Fire-Rated Doors
Penalty
Summary
The deficiency involves the failure to maintain the means of egress in accordance with adopted regulations, specifically concerning fire-rated doors. During observations on multiple occasions, it was noted that a 1½-hour rated kitchen door and an A-Wing 1½-hour rated soiled utility room door did not self-close and latch as required by the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition Chapter 5. A note was posted on the kitchen door instructing individuals to ensure the door was closed tightly, indicating a known issue. The facility's Fire/Smoke Door Inspection document, dated 12/29/2023, confirmed that fire-rated doors should self-close and latch, yet this was not occurring. Interviews conducted with a Maintenance and Life Safety Consultant and the Administrator revealed acknowledgment of the issue, with plans to adjust the doors to self-close and seat properly to the frame and to include them in a preventative maintenance program. However, these actions were not in place at the time of the survey, leading to the citation.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 What corrective action will be accomplished for those residents found to have been affected by the deficient practice? 1) The kitchen door was adjusted for proper closure and latching on 12/13/2024. The signage was removed which was temporarily placed there until maintenance could make the adjustments. The A-Wing soiled utility door was adjusted on 12/17/2024 for proper closure and latching. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? 2) All residents and staff have the ability to be affected by this deficient practice. An audit of all self-closing fire-rated doors will be conducted to ensure they all self-close and latch appropriately. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur? 3) All facility wide self-closing doors have been placed on the preventive maintenance program for monitoring and adjustments as/if needed. Education to be provided to maintenance staff on the location of and the requirements to ensure fire-rated doors self-close and latch. In addition, education will be provided to dietary, nursing and housekeeping staff on which doors are to be self-closing and to report to the maintenance staff (via work orders) when these doors do not self-close. How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction? 4) As part of the facility wide preventive maintenance program, all self-closing fire-rated doors will be checked with findings documented on the paper checklist. The entire facility preventive maintenance (which includes the aforementioned doors) program which details, daily, weekly, monthly, quarterly, semi-annual and annual activities will be submitted to the QAPI Committee beginning in January, 2025 to ensure all preventive maintenance activities have been completed and any needed corrective action has been completed. Responsible Party: Director of Maintenance