Corridor Door Latching Deficiency
Penalty
Summary
The facility was found to have a deficiency related to the maintenance of corridor doors, specifically in one of its five smoke compartments. During an observation conducted on February 10, 2025, at 11:45 a.m., it was noted that the door to the Ice Machine Room failed to latch properly. This failure to latch compromises the door's ability to resist the passage of smoke, which is a requirement for corridor doors in such facilities. The deficiency was confirmed during an exit conference with the Administrator and Maintenance Director on the same day at 1:15 p.m. The inability of the door to latch was acknowledged by the facility's representatives, indicating a lapse in maintaining the required safety standards for corridor doors. This issue affects the facility's compliance with regulations designed to ensure the safety and protection of residents and staff from smoke in the event of a fire.
Plan Of Correction
1) Parts were ordered for the door latch in the Ice Machine Room. 2) Maintenance will replace the latch when the part is received. 3) The maintenance director or designee will perform random weekly audits for 8 weeks, then monthly for two months, as part of a preventive maintenance plan to ensure corridor doors do not have problems closing. Results of the audit will be presented at the monthly QAPI meetings for review and or recommendations.