Failure to Maintain Corridor Door Functionality
Penalty
Summary
The facility failed to maintain the corridor doors as required by the NFPA 101 standards. During an observation on December 4, 2024, at 9:32 a.m., it was noted that the door to the laundry room, which is part of one of the two smoke compartments, was equipped with a self-closing mechanism. However, when tested, the door did not self-close and latch as it should have, indicating a deficiency in the door's functionality. This deficiency was confirmed during an interview conducted on the same day at 11:30 a.m. with the Facility Administrator, Regional Nursing Consultant, and Maintenance Assistant. The failure of the door to self-close and latch properly compromises the facility's ability to resist the passage of smoke, which is a critical safety requirement for corridor doors in long-term care facilities.
Plan Of Correction
The facility cannot retroactively correct the laundry room door that did not self-close and latch when tested. The laundry room door was corrected prior to the end of the survey. Audit has been completed on all other self-closing doors of the facility. No other concerns identified. Nursing Home Administrator/Designee will educate maintenance staff on corridor doors and self-closing doors. Maintenance Staff/Designee will audit self-closing corridor doors 5 times per week for 2 weeks, then weekly for 2 weeks, then monthly for 2 months to ensure doors self-close properly. The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review.