Failure to Ensure Proper Latching of Corridor Doors
Penalty
Summary
The facility failed to ensure that corridor doors were properly latched, which is a requirement for maintaining fire safety and smoke containment. During an observation on December 12, 2024, it was noted that the Housekeeping Closet door on the second floor was binding on the floor and failed to latch. Similarly, the Employee Storage Room door on the first floor also failed to latch. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director. Additionally, further observations on the same day revealed that the Nourishment Room door on the second floor and the Storage Room door near resident room 106 on the first floor also failed to latch. These findings indicate a pattern of non-compliance with the requirement for corridor doors to have positive latching hardware, as mandated by the NFPA 101 and CMS regulations. The failure to ensure proper latching of these doors affects the facility's ability to resist the passage of smoke, which is critical for the safety of residents and staff.
Plan Of Correction
The latch & door were repaired for the second floor Housekeeping Closet across from resident room 252. The latch was repaired for the employee storage room door on the first floor. Maintenance staff to be educated on ensuring corridor doors are latched. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee. The second-floor nourishment door latch was repaired. The first-floor storage room door near resident room 106 latch was repaired. Maintenance staff to be educated on ensuring corridor doors are latched. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee.