Corridor Door Deficiency in Smoke Compartment
Penalty
Summary
The facility failed to maintain a corridor opening in compliance with NFPA 101 standards, specifically affecting one of three smoke compartments. During an observation on January 22, 2025, it was noted that the door to Resident Room 9 was getting stuck on the flooring, which required excessive force to close. This issue was identified as a deficiency because it impeded the proper functioning of the door, which is required to resist the passage of smoke and close without impediment. The deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager on the same day. The report highlights that the door's inability to close properly could potentially compromise the safety measures intended to protect residents from smoke in the event of a fire. The report does not provide any additional information about the resident(s) involved or their condition at the time of the deficiency.
Plan Of Correction
1. The room 9 door was adjusted to fully latch. 2. A facility wide audit was conducted and no other doors in need of adjustment were identified. 3. The maintenance director was re-educated on ensuring all doors fully latch. 4. The NHA or designee will conduct a one-time audit to ensure room 9 positively latches. The results will be submitted to the QAPI committee for review and analysis of need of ongoing monitoring.