Deficiencies in Corridor Door Maintenance
Penalty
Summary
The facility failed to maintain corridor doors on three of its five floors, as observed during a survey conducted on December 12, 2024. The survey revealed that several corridor doors were either not smoke tight when latched or failed to positively latch in the frame. Specifically, the door to room 419 on the 4th floor was not smoke tight, the 3rd floor nurse lounge door had no latch, and doors to rooms 203, 217, and 227 on the 2nd floor were either not smoke tight or lacked a latch. During an exit conference on the same day, the administrator, maintenance representative, and regional facility representative confirmed these deficiencies. The report highlights that the facility did not meet the requirements for corridor doors as outlined by the NFPA 101 standards, which are crucial for ensuring the safety and containment of smoke in the event of a fire.
Plan Of Correction
All the observed doors were fixed to ensure positive latch and smoke tightness. NHA educated the Maintenance Director on maintaining corridor doors. An initial audit was completed to ensure positive latch and smoke tightness of corridor doors. NHA/designee will audit weekly x 4, then monthly X 3. Findings will be reviewed in the monthly QAPI.