Failure to Maintain Corridor Door Latching
Penalty
Summary
The facility failed to maintain the corridor doors to positively latch, which is a requirement for ensuring the safety and security of the smoke compartments. During an observation on December 17, 2024, at 9:49 AM, it was noted that the door to the Washington 3rd floor Supply Room, located next to Resident Room 3911, did not positively latch within the door frame. This deficiency affects one of the 43 smoke compartments within the facility. The Assistant Director of Facilities and Grounds confirmed during an interview at the same time and date that the corridor door did not latch properly. This failure to maintain the door's positive latching mechanism is a violation of the regulations that require doors protecting corridor openings to resist the passage of smoke and to have positive latching hardware, especially in areas that are not fully sprinklered.
Plan Of Correction
1. The Washington 3rd Supply Room door, next to Resident Room 3911, was corrected on 12/18/2024 to ensure that it positively latched within the door frame. 2. Maintenance staff will be educated that corridor doors protecting corridor openings in other than required enclosures of vertical openings, exits, hazardous areas will be maintained to ensure positive latching within the door frame. General staff education to initiate work orders when doors are not latching appropriately. 3. The Director of Security and/or Maintenance Assistant Director or designee will monitor the building monthly to ensure that corridor doors protecting corridor openings in other than required enclosures of vertical openings, exits, hazardous areas will be maintained to ensure positive latching within the door frame. The results of the audit will be forwarded to the Quality Assurance Committee for review and comment.