Deficiencies in Corridor Door Maintenance
Penalty
Summary
The facility was found to have deficiencies in maintaining corridor doors, as observed during a survey on January 29, 2025. Specifically, three corridor doors on different floors failed to latch when tested. These doors were located in rooms 6012 on the sixth floor, 3040 on the third floor, and 2013 on the second floor. The failure of these doors to latch properly was confirmed through an interview with the Facility Administrator and Maintenance Director. Additionally, two more deficiencies were noted in other parts of the facility. The door to Room 5114 on the fifth floor also failed to latch when tested. Furthermore, the door to Room 507 had two penetrations near the door knob, which could allow smoke to pass through. These issues were similarly confirmed by the Facility Administrator and Maintenance Director during the interview.
Plan Of Correction
The identified door latches (6012, 3040, 2013) were fixed on January 30th, 2025. Each hallway door will be inspected 1 floor per week for 6 weeks, then monthly to ensure that the door latched appropriately. Results will be reported to the quality assurance and performance committee. The identified door to Room 5114 was adjusted so that it would latch. The two penetrations adjacent to the doorknob on the door to Room 507 were fixed on January 30th, 2025. Each hallway door will be inspected for proper latching and door penetrations, 1 floor per week for 6 weeks, then one floor/month thereafter. Results will be reported to the quality assurance and performance committee.