Failure to Maintain Smoke Tight and Positively Latching Corridor Doors
Penalty
Summary
The facility failed to maintain corridor doors to be smoke tight and to positively latch, as observed on October 8, 2024. Specifically, the door to resident room 113 had a gap greater than 1/2 inch between the door and the frame, which was confirmed by the Director of Maintenance. Additionally, corridor doors at resident room 124 and the Activity Room had issues with positive latching, with the Activity Room double doors having the latch removed. A follow-up observation on December 9, 2024, determined that the issues identified in items 1 and 2 were not corrected. The Director of Maintenance confirmed during an interview that the deficiencies related to the corridor doors' smoke tightness and positive latching remained unresolved.
Plan Of Correction
1. The facility is unable to retroactively ensure corridor door gaps are within the allowed margin. 2. Maintenance Director completed facility-wide audit of all corridor doors. Doors will be adjusted as needed to ensure gaps conform to regulation. Fire/Smoke door seal will be installed on doors where adjustments won't close the gap to regulation. 3. Door to Room 124, and activity room will be corrected to positively latch. Fire/smoke door seal will be installed to close the gap on the door to room 113. 4. All staff will be educated on the need to report doors that do not positively latch. Maintenance staff will be educated on door gap regulatory requirements. Maintenance Director or Designee will complete audits monthly for 12 months. Results of the audits will be presented to the QAPI Committee for review and analysis of need for ongoing monitoring.