Corridor Door Deficiencies in Smoke Compartments
Penalty
Summary
The facility failed to maintain corridor doors in compliance with NFPA 101 standards, as observed during a survey on February 6, 2025. The deficiencies were noted in four instances across two of the twelve smoke compartments. Specifically, the door to the dining room on the eighth floor was improperly held open with rubber stoppers, which is not compliant with the requirement for doors to resist the passage of smoke. Additionally, three doors on the sixth floor, including those to Rooms 624 and 609, as well as Room 302, failed to latch properly when tested, indicating a failure to ensure positive latching hardware as required. These deficiencies were confirmed during an interview with the Facility Administrator and Maintenance Director on the same day. The failure to maintain proper door functionality could potentially compromise the safety and fire protection measures within the facility, as corridor doors are essential in preventing the spread of smoke and fire. However, the report does not detail any immediate consequences or risks to residents or staff resulting from these deficiencies.
Plan Of Correction
Identified doors will be fixed to latch by 3/21/2025. House audit was completed for fully closure and latching doors. 1 floor of doors will be audited per week for closure and latching for 4 weeks, then monthly by the Maintenance Director or designee. The administrator or designee will reeducate Maintenance director on Proper latching corridor doors -K363. Results will be reported to Quality Assurance and Performance Improvement committee meetings.