Failure to Maintain Corridor Door Latching
Penalty
Summary
The facility failed to maintain proper corridor door functionality on the 2nd floor, specifically at the Country Kitchen doors. These doors, which are equipped with self-closure mechanisms and are connected to the fire alarm system, did not latch into the frame when released from the hold open device. This deficiency was observed during a survey conducted on December 9, 2024, at 12:30 p.m. During an exit interview with the Facility Administrator, Director of Plant Operations, and Facilities Manager, it was confirmed that the doors failed to latch when tested. This issue affects the facility's compliance with regulations requiring corridor doors to resist the passage of smoke and to have positive latching hardware, especially in areas that are not fully sprinklered.
Plan Of Correction
The statements made in this Plan of Correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To maintain compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the facilities allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. 1. The Maintenance Director corrected the 2nd floor country kitchen doors to ensure they latch appropriately. 2. The Maintenance Director/Designee will conduct an initial audit to verify that country kitchen doors latch appropriately. 3. Nursing Home Administrator or Designee will re-educate the Maintenance Director on proper latching of dining room doors. 4. The Maintenance Director/Designee will conduct weekly audits for four weeks and then monthly for two months thereafter to verify that country kitchen doors latch appropriately. This plan of correction will be reviewed at the monthly Quality Assurance Performance Improvement meeting and changes will be made as needed.