Failure to Maintain Fire Resistive Rating of Exit Stair Enclosures
Penalty
Summary
Surveyors observed that the facility failed to maintain the fire resistive rating of exit stair tower enclosures across all four levels of the component. On the ground floor, all four rated doors inside the stairwell enclosure leading to the stair tower between Personal Care and Skilled Nursing did not positively latch. Additionally, a hollow wooden door, of unknown fire rating, was found sealed within a door frame set in a cinder block wall inside the stairway enclosure. These findings were confirmed during an exit interview with the Maintenance Supervisor and Director of Safety/Security. No information regarding residents' medical history or condition at the time of the deficiency was provided in the report.
Plan Of Correction
All non-latching doors have been adjusted and doors now latch appropriately. Doors will be monitored during environmental rounds by maintenance staff. The hollow area identified was tested and no door present behind sheetrock. That area consists of two layers of 5/8" sheetrock. Inspection holes were filled with red fire stop caulking to maintain fire barrier.