Failure to Maintain Corridor Door Latching
Penalty
Summary
The facility failed to maintain corridor doors in compliance with NFPA 101 standards, as evidenced by two separate observations. On February 3, 2025, during an inspection, it was observed that the Therapy door did not latch into the frame when tested. This deficiency was confirmed during an exit conference with the administrator and maintenance representative, indicating a lack of positive latching, which is required to resist the passage of smoke. Additionally, on the same day, another observation revealed that the door to Resident Room 307 on the 3rd floor also failed to latch in the frame when tested. This issue was similarly confirmed during the exit conference, highlighting a consistent problem with the facility's corridor doors not meeting the required standards for positive latching hardware, as mandated by CMS regulations.
Plan Of Correction
1. The Therapy door latch that failed to latch into the frame when tested will be repaired to proper function. 2. Additional corridor doors will be reviewed for proper function. 3. The Executive Director/ designee will educate the Maintenance Director on the importance of maintaining corridor doors to proper function in accordance with NFPA standards. 4. Any findings will be reported to the monthly QAPI Committee for further review. --- 1. The corridor door for resident room 307 that failed to latch will be repaired to proper function. 2. Additional corridor doors will be reviewed for proper function. 3. The Executive Director/ designee will educate the Maintenance Director on the importance of maintaining corridor doors for proper function in accordance with NFPA standards. 4. Any findings will be reported to the monthly QAPI Committee for further review.