Deficiency in Corridor Door Latching
Penalty
Summary
The facility failed to maintain corridor doors as required by regulations, specifically for one of over fifty corridor doors. During an observation on December 10, 2024, at 11:35 a.m., it was noted that the door to resident room 505 on the first floor did not have positive latching. This deficiency was identified through direct observation by the surveyors. The maintenance supervisor confirmed the deficiency during an interview conducted at the same time as the observation. The lack of positive latching on the corridor door is a violation of the requirements that ensure doors resist the passage of smoke and maintain safety standards within the facility.
Plan Of Correction
The door to room 505 was fixed immediately. All doors on A hall were checked and all passed. Education provided to maintenance as well as all staff on the importance of checking doors latching and process to report if it does not. Maintenance director or designee will audit 5 doors a week times 2 weeks and then weekly until cleared by quality assurance.