Deficiency in Corridor Door Maintenance
Penalty
Summary
The facility failed to maintain the corridor doors to positively latch and resist the passage of smoke, affecting two of ten smoke compartments. During an observation on February 5, 2025, at 2:10 PM, it was noted that the double doors to the Main Street Cafe, located by the Activity Room door, did not positively latch. This observation was confirmed through an interview with the Director of Plant Operations at the same time. Additionally, another observation on February 5, 2025, at 2:15 PM, revealed that the door to the Sunflower Cafe had a gap on the strike side greater than 1/2 inch, which compromised its ability to resist the passage of smoke. This deficiency was also confirmed in an interview with the Director of Plant Operations at the time of the observation.
Plan Of Correction
K-0363 (E) Corridor- Doors 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 ensure smoke, fire, and corridor doors will operate as per design. 1. The doors by room, the sunflower café, and double doors by main street café have had the doors repaired and now they close, latch, and are gap free as design. 2. Doors throughout the facility were checked to allow for closure; all residents are free from hazards and all systems are operating as designed as of 2/7/2025. 3. Education completed with maintenance staff regarding monitoring doors and rating labels to ensure they close properly on 2/7/2025. 4. Every quarter for a year, the Maintenance Director or designee will check random doors throughout the facility to ensure the doors are fully closed. This information will then be entered on a log and will be presented to the monthly QAPI meeting.