Facility Fails to Maintain Smoke-Tight Corridor Doors
Penalty
Summary
The facility failed to maintain smoke-tight corridor openings in several locations, affecting multiple floors. During an observation on February 11, 2025, it was noted that the doors to resident rooms 307 and 302 were not smoke-tight. This deficiency was confirmed during an exit interview with the Facility Administrator and Facilities Manager. Additionally, another observation on the same day revealed that the door to Resident Room 104 on the first floor was also not smoke-tight. This issue was similarly confirmed during the exit interview with the Facility Administrator and Facilities Manager. These deficiencies indicate a failure to comply with the requirements for corridor doors to resist the passage of smoke, as outlined in NFPA 101 and CMS regulations.
Plan Of Correction
Room 307 and 302 Doors were adjusted to be smoke tight. Facility Door Audit was completed of all doors to ensure they are smoke tight. Maintenance will be educated by NHA/Designee re: K-0363. Maintenance director or designee will audit all doors for 3 months and then quarterly. All findings will be reported at Monthly QPI meeting. Room 104 Door was adjusted to be smoke tight. Facility Door Audit was completed of all doors to ensure they are smoke tight. Maintenance will be educated re: K-0363 by NHA/designee. Maintenance director or designee will audit all doors for 3 months and then quarterly. All findings will be reported at Monthly QPI meeting.