Corridor Door Latching and Obstruction Deficiencies
Penalty
Summary
The facility failed to maintain corridor doors to positively latch and remain unobstructed from closing in two of four smoke compartments. During an observation on December 16, 2024, at 1:20 PM, it was noted that the Main Dining Room double doors, located directly in from the Main Entrance, did not positively latch when closed. This deficiency was confirmed through an interview with the Director of Maintenance at the same time. Additionally, at 1:40 PM on the same day, the corridor door to Resident Room 403 was found to be impeded from closing due to a decoration hanging on the door knob. This obstruction was also confirmed by the Director of Maintenance during an interview conducted at the time of the observation.
Plan Of Correction
1. The main dining room double door was repaired. The decoration was removed from the doorknob of room 403. 2. The Maintenance Supervisor will receive re-education by the administrator on indoor door closure and impeding door closures. 3. The facility will complete an initial audit of all facility doors then 5 random facility doors monthly for 1 year to ensure adequate door closure and no impeded door closures. 4. Audits will be reviewed at the next QAPI meeting. 5. The facility will be in substantial compliance by 2/14/2025.