Corridor Door Fails to Latch, Compromising Smoke Resistance
Penalty
Summary
The facility failed to ensure that corridor doors were maintained to resist the passage of smoke and positively latch, as required by regulations. During an observation on February 4, 2025, at 10:50 a.m., it was noted that the door to resident room 211 on the second floor did not positively latch in the frame. This deficiency was identified as one of over three hundred corridor doors within the facility. The issue was confirmed during an exit interview with the Maintenance Director on the same day at 1:00 p.m. The report highlights that the door's inability to latch properly compromises its function to resist smoke passage, which is a critical safety requirement in long-term care facilities. The deficiency was observed and documented by surveyors, indicating a lapse in the facility's maintenance of safety standards for corridor doors.
Plan Of Correction
Exit Date: 02/04/25 0363 Scope/ Severity: E NFPA 101 STANDARD Corridor - Doors: Name - BLDG. 8 Component - 05 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. Observations: Based on observation and interview, it was determined the facility failed to ensure that corridor doors were maintained to resist the passage of smoke and positively latch on one of over three hundred corridor doors within the facility. Findings include: Observation on February 4, 2025, at 10:50 a.m., revealed, on the second floor, resident room 211, failed to positively latch in the frame. Exit interview with the Maintenance Director on February 4, 2025, at 1:00 p.m., confirmed the door did not latch. Plan of Correction: Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0363 Door was repaired to latch in the frame. Door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated.