Non-compliance with Stairtower Door Standards
Summary
The facility failed to maintain the stairtower doors in compliance with NFPA 101 standards on one of four floors. During an observation, it was noted that the 4th floor 2D stairtower door had gaps greater than the allowed 3/16 inch, which was confirmed by the Director of Maintenance. Additionally, the 4th floor 1D stairtower door had broken panic hardware, was patched, and could not be opened as it was held closed with a 2 x 4 on the stairtower side. This was also confirmed by the Director of Maintenance during the interview.
Plan Of Correction
The Maintenance Director will repair the 4th floor hallway 2D stair tower door so there is no gap greater than 3/16 inch. The Maintenance Director will secure a contractor to replace the 4th floor hallway 1D stair tower door. The facility is requesting a Time-Limited Waiver for 1D replacement to be completed no later than 5/10/2025. The Maintenance Director or Designee will audit all stair tower doors to ensure that there are no gaps greater than 3/16 inch. The Maintenance Director or Designee will audit all stair tower doors to ensure that the hardware is functioning properly. The Maintenance Director or Designee will do random monthly audits every 90 days of all stair tower doors to ensure that there are no gaps greater than 3/16 inch and that the hardware is functioning properly. The Maintenance Director or Designee will present findings at the QAPI meetings for review and/or recommendations.
Penalty
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Stair tower doors on two building levels were found blocked by a caution retractable rope and signage instructing that the stairs were only for emergency use, which could delay resident egress. The maintenance director confirmed this setup during the survey.
A stairtower door near the South Nurses' Station was found not to latch properly because of incorrectly mounted magnet hardware. This deficiency was confirmed by the DON and Director of Maintenance during the survey.
Surveyors found that all rated doors inside a stairwell enclosure between Personal Care and Skilled Nursing failed to positively latch, and a hollow wooden door of unknown fire rating was sealed within a fire-rated wall. These issues were confirmed by facility staff.
An observation revealed that the electronic stairway path interrupter on the 2nd floor egress by the elevators was not functioning, which could cause individuals to miss the correct exit during an emergency. This issue was confirmed with the Maintenance Director and could affect a significant number of residents during a fire.
The facility did not maintain stairtower doors within the allowed gap margins on two floors. Observations revealed that the doors on the 1st and 2nd floors of Stairtower A had gaps exceeding 1/8 inch, confirmed by the Director of Maintenance.
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Stairway Exits Blocked by Caution Rope and Signage
Penalty
Summary
During an observation, it was found that stair tower doors on two of five building levels were blocked by a caution retractable rope with signage stating, "STOP!! DO NOT USE STAIRS ONLY FOR EMERGENCY." This setup prevented residents from using the stairways as exits except in emergencies, which could impede their ability to exit promptly. The maintenance director confirmed the presence of the rope and signage at the time of the survey. No additional information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
The systematic change will be to have the retractable rope become a breakaway rope so not to impede progress through the stair tower door. The Director of Maintenance will audit all stairwell doors to assure there a retractable rope in place and report findings to Monthly Quality Assurance meeting.
Stairtower Door Failed to Latch Due to Improper Hardware
Penalty
Summary
A deficiency was identified when the first floor stairtower door, located by the South Nurses' Station, failed to latch properly in its frame. This issue was observed during a facility inspection and was attributed to improperly mounted magnet hardware on the door. The failure of the door to positively latch was confirmed during an interview with the Director of Nursing and the Director of Maintenance at the time of the exit conference. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
1. The first floor stair tower door's hardware was adjusted to ensure positive latch. 2. A facility-wide audit was completed to ensure positive latch of required doors. 3. The Environmental Services Director was re-educated on the requirements of K0225. Monthly door latch audits will occur. 4. The NHA or designee will complete a random audit of facility doors weekly x 4 weeks then monthly x 2 months to ensure positive latch. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.
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.
Inoperative Stairway Path Interrupter on 2nd Floor Egress
Penalty
Summary
During an observation on April 14, 2025, it was found that the electronic stairway path interrupter installed on the 2nd floor stairway path of egress by the elevators was inoperative. This device is intended to guide occupants to the proper egress level during emergencies. The inoperative condition could result in individuals evacuating to the lower level and missing the correct exit during a fire or emergency event with diminished visibility. The deficiency was confirmed at the time of observation with the facility Maintenance Director. A total of 58 out of 175 residents could be affected by this issue in the event of a fire situation, as noted in the findings.
Plan Of Correction
K225- Stairways and Smoke Proof Enclosures 1. The facility has failed to ensure stairways and smokeproof enclosures used as exits are in accordance with 7.2, as required by 19.2.2.3 and 19.2.2.4. 2. The electronic stairway path interrupter installed on the 2nd floor stairway path of egress by the elevators is operative. 3. The maintenance director and staff will be educated on the importance of egress doors/gates being continuously activated and working properly. 4. To ensure continued compliance is maintained with the stairway path interrupter, the Maintenance Director/Designee will complete random audits 5x a week for 4 weeks. Findings will be reported to the QAPI committee. 5. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.
Stairtower Door Gap Deficiency
Penalty
Summary
The facility failed to maintain the stairtower doors within the allowed gap margins on two of three floors. During an observation on April 15, 2025, at 1:20 PM, it was noted that the doors on the 1st and 2nd floors of Stairtower A had gaps greater than 1/8 inch. This was confirmed in an interview with the Director of Maintenance at the same time.
Plan Of Correction
1st and 2nd Floor Stairtower A doors will be corrected to be within the allowed gap margins. Maintenance Staff were educated on Stairways and Smokeproof Enclosures. Stairways used as exits cannot have gaps greater than 1/8 gap. Director of Plant Operations or designee will audit 1 time a month. Audits will be reported at QAPI.
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