Failure to Maintain Positive Latching of Corridor Door
Penalty
Summary
The facility failed to maintain the positive latching of corridor doors, specifically affecting one of the seven smoke compartments within the component. During an observation conducted on January 27, 2025, at 9:59 AM, it was noted that the door to the Sun Room on the 3rd floor did not positively latch within the door frame. This deficiency was identified through direct observation and was confirmed during an interview with the Senior Maintenance Director at the same time. The report highlights that the corridor doors are required to resist the passage of smoke and have positive latching hardware, as per the NFPA 101 standards and CMS regulations. The failure of the door to latch properly compromises the safety standards set for corridor doors, which are crucial in preventing the spread of smoke in the event of a fire. The deficiency was observed and confirmed by the facility's Senior Maintenance Director, indicating a lapse in maintaining the required safety standards for corridor doors.
Plan Of Correction
1. The door mentioned was repaired on 1/29/25 and now operates and latches properly. 2. The Maintenance Director will conduct a one-time facility-wide audit on all corridor doors to ensure smoke tight doors and positive latching within the door frame. 3. Monthly audits will be completed to check latching on random corridor doors thereafter. 4. Findings will be reported to QAPI for review each quarter.