Failure to Maintain Corridor Door Latching
Penalty
Summary
The facility failed to maintain corridor doors in compliance with NFPA 101 standards, specifically in one instance affecting one of fifteen smoke compartments. During an observation on January 7, 2025, at 10:30 a.m., it was noted that the door to room 347 on the third floor did not latch when tested. This deficiency was identified as a failure to ensure that corridor doors resist the passage of smoke and are equipped with positive latching hardware, as required by CMS regulations. The deficiency was confirmed through an interview with the Facility Administrator and Maintenance Director on the same day at 1:00 p.m. The report does not provide additional details about the residents or specific conditions in room 347 at the time of the observation. The focus of the deficiency is on the failure of the door to latch properly, which is a critical component of maintaining fire safety and smoke containment in the facility.
Plan Of Correction
The door on room 347 was adjusted and now latches properly. Other doors in the facility were inspected and all have been verified to latch correctly. Maintenance staff are aware of K 0363 and how it is applicable to Patriot Village. Maintenance staff will conduct an audit of 15 doors monthly for two months. Results will be reviewed at the Quality Assurance Performance Improvement meeting.