Fire-Rated Door in Hazardous Area Improperly Propped Open
Penalty
Summary
During a facility tour conducted with the Director of Maintenance (DOM) and the Administrator, surveyors observed that a fire-rated door in the kitchen exit passage leading into a hazardous dry storage room was not maintained in accordance with NFPA 101 standards. The door, which is protected by a one-hour fire barrier and equipped with a self-closing device, was found to be held open by a bungee cord wrapped around the door handle. Additionally, a storage rack was positioned in such a way that it further restricted the door from self-closing and latching as required. The Administrator, when interviewed at the time of the observation, confirmed the findings and acknowledged that the door should be kept closed. The report specifies that such doors are only permitted to be held open by an automatic release device that complies with NFPA 101 section 7.2.1.8.2, which ensures the door will close automatically upon activation of the fire alarm, sprinkler system, smoke detection system, or loss of power. In this instance, the door was not equipped with such a device and was instead manually propped open, which is not compliant with the cited regulations. No information was provided in the report regarding any residents or staff being directly affected at the time of the deficiency, nor was there mention of any medical history or specific conditions related to individuals in the facility. The deficiency was based solely on the physical observation of the door's condition and the facility's failure to maintain required fire safety standards for doors with self-closing devices in hazardous areas.
Plan Of Correction
1) No residents were identified. 2) No residents were identified. 3) Administrator immediately discarded bungee cord found to be propping fire door open on 08/04/2025. An in-service education was conducted by the Administrator, Director of Plant Operations, or designee on 08/21/2025 with staff addressing the maintaining doors with self-closing devices in accordance with NFPA 101 (2012 Edition). 4) The Director of Plant Operations, or designee, will audit at random five (5) Fire Rated Doors to observe if the door is free from devices that would prevent self-close and latch. Audits will be conducted once a week for four weeks, once a month for two months, or until substantial compliance is achieved. The results of the audit will be forwarded to the Quality Assurance Committee for review monthly for at least three months with a goal of 100% compliance. Upon completion and 100% compliance for at least three months is achieved, the frequency of further review and ongoing need for review will be determined by the QAPI committee. The same information is repeated in the original text, so it is presented here as a continuous paragraph for clarity.