Deficiency in Corridor Door Smoke-Tightness
Penalty
Summary
The facility failed to maintain a smoke-tight corridor opening, specifically affecting the door to resident Room 122 on the first floor. This deficiency was identified during an observation conducted on December 23, 2024, at 11:23 a.m. The door did not meet the requirement to resist the passage of smoke, which is essential for ensuring the safety and protection of residents in the event of a fire or smoke emergency. During an exit interview with the Facility Administrator and the Facilities Manager later that day, the deficiency regarding the corridor opening was confirmed. The report does not provide additional details about the specific condition of the door or any immediate impact on the residents, but it highlights a failure to comply with the necessary fire safety standards as outlined in the NFPA 101 and CMS regulations.
Plan Of Correction
Resident # 122 Room Door was corrected and made smoke tight. Corridor doors were audited and are all smoke tight. NHA/Designee educated the Maintenance Director on NFPA 101-Corridor Doors. Maintenance Director will randomly audit Corridor doors 1x week for 4 weeks then monthly x2.