Failure to Maintain Fire-Resistant Door Barriers
Penalty
Summary
Surveyors observed that the facility failed to maintain the required fire resistance rating for common wall fire separations in one of three levels. Specifically, during an inspection, deficiencies were identified with fire-rated doors in the basement elevator lobby area. One double fire door had several penetrations on the door leaf and in the metal door frame, and another fire door showed penetrations and extensive damage at each hinge location. These conditions were directly observed by surveyors during their walkthrough. The deficiencies were confirmed in interviews with the Administrator and Maintenance Director, who acknowledged the issues with the fire doors. The report does not mention any specific patients or residents affected, nor does it provide details about their medical history or condition at the time of the deficiency. The focus of the findings is on the physical environment and the failure to maintain fire-resistant barriers as required by NFPA 101 standards.
Plan Of Correction
The fire door with penetrations has been replaced. Other fire doors in the center will be checked to ensure that they are free of penetrations. The Maintenance Director and/or designee will perform audits weekly, for four weeks and monthly for two months to ensure that the fire doors are free from penetrations. Results of the audits will be reported to QAPI.