Deficiency in Corridor Door Smoke Resistance
Penalty
Summary
The facility failed to ensure that doors protecting corridor openings could resist the passage of smoke, which is a requirement for safety in long-term care facilities. This deficiency was observed on the third floor, specifically at the double doors near resident room 310. The doors were found to have a metal door frame with open penetrations above the closer, which compromises their ability to prevent smoke from passing through. During an exit interview with the Executive Director of Construction and Ancillary Services, it was confirmed that the metal door frame had penetrations. This issue affects one of the twenty-four floors in the facility, indicating a lapse in maintaining the required safety standards for corridor doors, particularly in smoke compartments.
Plan Of Correction
ED of construction to Inservice supervisor of plants operations on policy and procedure regarding corridor doors. Door closures will be installed in the same open mounting holes at top of frame to ensure smoke doesn't pass. Supervisor of Plant Operations to conduct audits 3x per week x 4 weeks to ensure all corridor doors are smoke tight in accordance with policies and procedures. Supervisor of Plant Operations or delegate to complete audits 3x per week x 4 weeks to compliance with policy and procedure. Audit findings will be submitted to QAPI committee monthly for review and recommendations as needed.