Failure to Maintain Corridor Door Latching
Penalty
Summary
The facility failed to maintain corridor openings in compliance with NFPA 101 standards, as observed during a survey on December 30, 2024. The survey revealed that several doors on both the first and second floors did not latch into their frames, compromising their ability to resist the passage of smoke. Specifically, the Living Room doors on the second floor, the Resident Room B-17 door, the Dr's Office door on the first floor, and the Shower Room door all failed to latch properly. Additionally, the Dr's Office door was noted to be not smoke-tight. These deficiencies were confirmed during an exit interview with the Facility Administrator, Assistant Administrator, and a Facility Representative. The failure of these doors to latch properly and maintain smoke-tight conditions indicates a lapse in maintaining the required fire safety standards, potentially affecting the safety of the facility's environment.
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 or Federal regulatory requirements. a. The closer of the second floor living room doors was adjusted to ensure latching and the work was documented in work order # 20321910. b. The door to resident room B-17 was adjusted to ensure latching and the work was documented in work order #20321911. c. The door to the Doctor's office on the first floor was repaired and adjusted to ensure that it latched and was smoke-tight. The work was documented in work order # 20321916. d. The door to the first-floor shower room was adjusted to ensure latching and the work was documented in work order #20321917. The Facilities Manager or his designee will maintain compliance through monthly safety rounding to identify and correct issues related to door closure and integrity. All four of the corrective actions were completed by January 2, 2025. The Facilities Manager is responsible to ensure that corrections are completed and documented in the maintenance work order program.