Deficiency in Corridor Door Integrity
Penalty
Summary
The facility failed to maintain the integrity of two corridor openings, which affected one of the two floors. During an observation conducted on December 16, 2024, it was noted that the door to Resident Room 125 on Unit 1 was not smoke tight when latched into the frame. This indicates that the door did not meet the required standards for resisting the passage of smoke, which is a critical safety feature in long-term care facilities. Additionally, the door to Resident Room 120 on the same unit failed to latch into the frame when tested. This deficiency was confirmed during an exit interview with the Facility Administrator on the same day. The failure of these doors to function properly compromises the safety measures intended to protect residents from smoke in the event of a fire, as they do not provide the necessary barrier to prevent smoke from entering the corridor.
Plan Of Correction
1. Resident Room Doors 125 & 120 had adjustments made to the frames to eliminate the gap and ensure smoke tight closure. 2. Corrective action was completed on 12/16/24. 3. Administrator / Designee will educate maintenance staff on K363 regarding corridor doors and maintaining sufficient smoke tight closure. 4. Maintenance Staff will conduct random inspections of resident room doors to identify other potential closure issues. Inspections will be conducted weekly x 4 weeks and results will be submitted to the QA committee.