Corridor Door Deficiency in Library Room
Penalty
Summary
The facility failed to maintain corridor openings in compliance with the National Fire Protection Association (NFPA) 101 standards. During an observation on February 13, 2025, it was noted that the distance between the doors of the Library Room on the first floor exceeded the allowable one-eighth-inch gap. This deficiency was identified as affecting one of the two floors in the facility. The issue was confirmed during an exit interview with the Facility Administrator and the Facilities Manager on the same day. The report highlights that the corridor doors did not meet the required specifications to resist the passage of smoke, as stipulated by the NFPA 101 and CMS regulations. This deficiency indicates a failure to adhere to fire safety standards, which are critical for ensuring the safety of residents and staff in the event of a fire.
Plan Of Correction
This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because The Williamsport Home agrees with the allegations and citations listed on the statement of deficiencies. The Williamsport Home maintains that the alleged deficiencies do not, individually, and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as The Williamsport Home's written credible allegation of compliance. By submitting this plan of correction, The Williamsport Home does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and The Williamsport Home reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding. 1. The Library Room doors will be fixed to not exceed a one-eighth-inch gap by March 7, 2025. 2. A full house audit will be conducted by maintenance personnel on all corridor doors to ensure door gaps do not exceed a one-eighth inch by February 28, 2025. 3. The Nursing Home Administrator or designee will conduct training/education with maintenance personnel regarding the requirement of K0363 by March 7, 2025. 4. An audit on corridor door openings will be conducted weekly x 2 and then monthly x 2 by the Maintenance Director or designee. The results of the audit will be taken to monthly QA by the Maintenance Director for review.