Deficiencies in Door Maintenance Affecting Smoke Compartments
Penalty
Summary
The facility was found to have deficiencies in maintaining hazardous area enclosures and corridor openings, affecting smoke compartments. On December 30, 2024, an observation revealed that the door to the Soiled Utility Room on the second floor was not smoke-tight, which is a requirement for hazardous area enclosures. This deficiency was confirmed during an exit interview with the Facility Administrator. Additionally, another deficiency was noted on the same day when the first-floor Dietary door failed to close and latch properly due to door drag. This issue was also confirmed during the exit interview with the Facility Administrator. Both deficiencies indicate a failure to comply with the requirements for doors protecting corridor openings, which are essential for resisting the passage of smoke and ensuring safety in the event of a fire.
Plan Of Correction
1. Door will be replaced so it will close and latch properly. 2. Other doors enclosures will be checked to verify closing and latching. 3. Maintenance will be re-educated on ensuring that all door enclosures are closing and latching. 4. Maintenance Director/ designee will conduct random audits to verify that door enclosures are closing and latching weekly for 4 weeks and then monthly for 2 months thereafter. Audits results will be presented at the QAPI meeting for review and recommendations.