Corridor Door Latching Deficiency
Penalty
Summary
The facility failed to meet the corridor door requirements as outlined by NFPA 101 and CMS regulations. During an observation on January 22, 2025, it was noted that the door to resident room #129 did not positively latch in the frame. This deficiency was identified as a failure to comply with the requirement that corridor doors must resist the passage of smoke and have positive latching hardware, especially in fully sprinklered smoke compartments. The maintenance supervisor confirmed the deficiency during an interview conducted at the same time as the observation. The report does not provide additional details about the resident in room #129 or any specific medical history or condition. The focus of the deficiency is on the physical infrastructure of the facility, specifically the corridor door's inability to latch properly, which is a critical component of fire safety and smoke containment in the facility.
Plan Of Correction
Maintenance immediately adjusted room 129 door to ensure closure and latch properly. Maintenance audited all resident doors to ensure doors were operating correctly. Maintenance director/designee to educate maintenance staff by 21MAR2025 on importance of proper door closure. Maintenance Director/designee will do weekly x4 audit of all resident room doors to make sure that doors are closing and latching correctly. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.