Deficiencies in Corridor Door Maintenance
Penalty
Summary
The facility was found to have deficiencies in maintaining corridor doors, as observed during a survey on December 23, 2024. Specifically, there was a hole above the door knob to the medication room, which compromises the door's ability to resist the passage of smoke. Additionally, the door to room C132, which is equipped with a door closer, failed to self-latch when tested. These issues were identified in two of the seven smoke compartments within the facility. The deficiencies were confirmed through an interview with the Facility Administrator and Maintenance Supervisor on the same day. The failure to maintain the integrity of corridor doors as required by NFPA 101 and CMS regulations indicates a lapse in ensuring that doors resist the passage of smoke and maintain proper latching mechanisms. This oversight affects the safety and compliance of the facility's smoke compartments.
Plan Of Correction
1. No Residents were found to have been harmed by the deficient practice. On 12-30-24, the Director of Maintenance completed repairs on the hole in the Medication Room door, and the hinge keeping room C132 from latching properly. 2. All Residents have the potential to be harmed by the deficient practice. 3. The Director of Maintenance was educated on regulation K 0363 by the Administrator. The Administrator, or designee, will perform weekly rounds with the Director of Maintenance, or designee, to check for compliance. 4. The Administrator will receive weekly emails from TELS, a software which schedules and tracks maintenance tasks, updating the status of the monthly visual inspection for monitoring purposes.