Failure to Maintain Corridor Door Latching
Penalty
Summary
The facility failed to maintain corridor doors in compliance with NFPA 101 standards, specifically in one of the five smoke compartments. During an observation on February 10, 2025, at 11:30 a.m., it was noted that the door to B-wing Room 301 did not close and latch properly when tested. This deficiency was identified as a failure to ensure that doors protecting corridor openings resist the passage of smoke and are equipped with positive latching hardware, as required by CMS regulations. An interview conducted with the Facility Administrator and Maintenance Director on the same day at 12:30 p.m. confirmed the observation that the door failed to latch when tested. This indicates a lapse in the facility's maintenance of corridor doors, which is crucial for ensuring the safety and compliance of the smoke compartments within the facility.
Plan Of Correction
1. The facility immediately corrected the door to B-Wing Room 301 by removing the isolation bag that was hanging over the door. The door can close and latch when tested. 2. The Nursing Home Administrator/designee will educate staff to ensure any door with isolation bags are not a barrier for the fire doors to close and latch. 3. The maintenance staff/designee will audit weekly for two months and then monthly for two months to ensure that no doors are blocked from closing or latching. 4. Any concerns will be brought to the Quality Assurance Performance Improvement Committee for review.