Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Penalty
The facility failed to maintain a fire-rated door separating Nursing Care from Assisted Living, compromising fire safety. The door had been modified, resulting in gaps and unauthorized repairs, affecting one of ten smoke compartments. The Director of Plant Operations confirmed these deficiencies.
The facility failed to maintain the fire resistance rating of fire doors on the first floor due to the absence of a bottom latching device. This issue was initially observed and confirmed during an inspection in December and remained unresolved during a follow-up revisit in February.
The facility failed to maintain fire resistance on one of three floors. Observations revealed unsealed penetrations around data lines and malfunctioning double doors by the Staff Development Office, which did not close or latch properly and had broken hardware. These issues were confirmed during an exit interview with the Administrator and Maintenance Director.
The facility did not maintain the fire resistance of common walls, affecting one smoke compartment. Observations revealed four unprotected penetrations in the wall separating the 01 and 02 Components, located above the ceiling and doors. Three penetrations were around wires, and one was empty. The Maintenance Manager confirmed these findings.
The facility failed to maintain common wall doors on the second floor, with gaps exceeding 1/8 inch and lacking positive latching. The doors were only secured by a magnetic release, allowing them to open freely during a fire alarm, as confirmed by the Director of Maintenance.
The facility failed to maintain the fire resistance rating of fire doors, as observed when a fire door on the first floor lacked bottom latching. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director.
Fire-Rated Door Deficiency in Smoke Compartment
Penalty
Summary
The facility failed to maintain the integrity of a fire-rated door, which is crucial for ensuring safety in the event of a fire. During an observation, it was noted that the corridor fire-rated door, which separates the Nursing Care area from the Assisted Living area at the breezeway end of the 600 Wing, had been improperly modified. The door had been planed on the strike edge, resulting in gaps greater than 1/8 inch, and a hole in the door had been filled with an unauthorized product. These modifications compromised the door's fire-rating capabilities. The Director of Plant Operations confirmed these deficiencies during an interview conducted at the time of the observation. This issue affected one of the ten smoke compartments within the component, indicating a lapse in maintaining the required fire safety standards as per NFPA 101 guidelines.
Plan Of Correction
This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. It is the practice of the facility to have proper fire rated doors separating Nursing and Assisted Buildings. 1. Replacement of the fire-rated door separating six hundred wings from the assisted living building has been ordered. New fire rated latching hardware will be installed as well. Residents are free from hazards. 2. All rated doors have been inspected, and confirmation of latching and free from gaps completed on 2/7/2025. 3. Education is completed with Maintenance staff to confirm proper door operation of doors on 2/7/2025. 4. Every quarter for a year the Maintenance Director or designee review random doors throughout the building for proper operations. This information will then be entered on a log and will be presented to the QAPI meeting.
Fire Door Deficiency Due to Lack of Bottom Latching
Penalty
Summary
The facility failed to maintain the fire resistance rating of fire doors, specifically on the first floor, where the fire door did not have a bottom latching device. This deficiency was initially observed on December 12, 2024, during an inspection at 10:00 a.m. The absence of the bottom latching was confirmed during an exit interview with the Administrator and Maintenance Director at 10:30 a.m. on the same day. During a follow-up onsite revisit conducted on February 4, 2025, between 08:15 a.m. and 11:00 a.m., it was determined that the issue had not been resolved. The component separation fire door on the first floor still lacked a bottom latching device, as confirmed in an exit interview with the Administrator at 11:00 a.m.
Plan Of Correction
The first-floor fire door bottom latching has been repaired. Maintenance staff to be educated on the importance of maintaining fire resistance rating of fire doors. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee.
Fire Barrier Deficiencies on First Floor
Penalty
Summary
The facility failed to maintain the fire resistance of fire barriers, affecting one of three floors. During an observation on January 30, 2025, between 9:05 a.m. and 9:15 a.m., deficiencies were noted on the first floor regarding common fire wall separations. Specifically, there was an unsealed penetration around data lines above the double doors by the Staff Development Office. Additionally, the double doors by the Staff Development Office failed to close and positively latch when tested, and there was broken hardware on the door. These findings were confirmed during an exit interview with the Administrator and the Maintenance Director on the same day at 11:30 a.m.
Plan Of Correction
Step 1 The maintenance team used 3M fire barrier sealant CP25B+ to seal penetration around data lines above the double door by the staff development office. Hardware on double doors repaired. Doors now positively latch and are closing appropriately. Step 2 The maintenance director/designee completed an audit of all doors to ensure safe operation. Smoke barriers were inspected throughout the building to ensure that there were no other unsealed penetrations. Repairs were completed for any deficiencies found. Step 3 The maintenance team was educated on the requirement to ensure the safe operation of all doors in the facility and to ensure that smoke barrier walls have no unsealed penetration. Step 4 The maintenance director/designee will complete a random audit of doors monthly x 4 to ensure safe operation. Findings will be reviewed during QAPI meeting.
Failure to Maintain Fire Resistance of Common Walls
Penalty
Summary
The facility failed to maintain the fire resistance of building separating common walls, which affected one of the 14 smoke compartments within the component. During an observation, it was noted that there were four unprotected penetrations in the common wall separating the 01 and 02 Components. These penetrations were located above the suspended ceiling, above the double doors, on the 01 Component side. Specifically, three penetrations were found around groups of wires, and one penetration was empty. This deficiency was confirmed through an interview with the Maintenance Manager, who acknowledged the unprotected penetrations of the fire wall.
Plan Of Correction
The four penetrations of the common wall, separating the 01 and 02 components above the suspended ceiling above the double doors will be corrected by the Maintenance Manager using an approved through penetration fire stop system. The Maintenance Manager or designee will conduct an audit of corridor walls weekly for one month. Monthly fire walls inspections will be added to PM schedule to check for penetrations and caulking in place to ensure the facility maintains the rating of the common wall. Deficient findings will be reported to DES and QAPI meeting.
Deficiency in Common Wall Door Maintenance
Penalty
Summary
The facility failed to maintain the integrity of common wall doors on the second floor, as observed during a survey on January 23, 2025. Specifically, the common wall door at the bridge to the elevator had gaps greater than 1/8 inch, which exceeds the allowed gap margins. This deficiency was confirmed through an interview with the Director of Maintenance, who acknowledged that the door did not meet the required standards. Additionally, another observation on the same day revealed that common wall doors on the second floor by the East Lounge also had gaps greater than 1/8 inch and lacked manual positive latching. These doors were only held closed by a coded magnetic release, which allowed them to open freely when the fire alarm was activated. The Director of Maintenance confirmed these findings, indicating that the doors did not comply with the necessary safety requirements.
Plan Of Correction
1. The distance between the common wall doors by the East lounge have been adjusted and corrected to meet one-eighth-inch requirement. 2. Door was adjusted to ensure manual positive latching. 3. Facility Maintenance Director or his designee will audit random doors for gaps for the next 3 months and then quarterly. 4. Maintenance Director will report findings to the QAPI committee.
Fire Door Deficiency Due to Lack of Bottom Latching
Penalty
Summary
The facility failed to maintain the fire resistance rating of fire doors, which is a requirement for ensuring safety in multiple occupancies. During an observation on December 12, 2024, at 10:00 a.m., it was noted that a fire door on the first floor lacked bottom latching. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director at 10:30 a.m. on the same day.
Plan Of Correction
The first-floor fire door bottom latching was repaired. Maintenance staff to be educated on the importance of maintaining fire resistance rating of fire doors. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee.
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