Failure to Maintain Corridor Doors
Penalty
Summary
The facility failed to maintain corridor doors in compliance with NFPA 101 standards, as evidenced by two specific instances where doors did not latch properly. During an observation on February 12, 2025, it was noted that the door to resident room 127 and the door to the Staff Lounge on Level 2 would not close and latch in their frames. This deficiency affects two of the sixteen smoke compartments within the facility. The issue was confirmed through an interview with the Facility Administrator and Maintenance Director on the same day. The inability of these doors to latch properly indicates a failure to meet the requirements for corridor doors, which are essential for resisting the passage of smoke and ensuring safety in the event of a fire. The report does not mention any specific residents' medical history or conditions related to this deficiency.
Plan Of Correction
Adjustments and repairs will be made to the following doors: 127 and level 2 staff lounge. Random audits will be completed monthly for three months. Maintenance staff will be educated on the importance of the latching of the doors. Results will be reported at the monthly Quality Assurance and Performance Improvement meeting.