Non-Compliance with Corridor Door Smoke-Tightness
Penalty
Summary
The facility was found to be non-compliant with the Life Safety Code requirements during a Medicare/Medicaid Recertification Survey. Specifically, the deficiency was related to the maintenance of corridor doors, which are required to resist the passage of smoke in a fully sprinklered smoke compartment. The survey identified that two corridor doors, numbered 401 and 403, were not smoke-tight, thus failing to meet the necessary safety standards. The observation of these deficiencies occurred on January 22, 2025, between 10:44 a.m. and 10:45 a.m. The issue was confirmed during an exit interview with the Facility Administrator and the Facilities Manager later that morning. The deficiency affected one of the nine smoke compartments in the facility, indicating a lapse in maintaining the required safety measures for corridor openings.
Plan Of Correction
Corridor doors on rooms 401 and 403 will be adjusted or modified to achieve smoke tight integrity. The facilities computerized maintenance system will schedule a monthly work order to inspect the doors for smoke-tight integrity.