Failure to Maintain Corridor Doors
Penalty
Summary
The facility failed to maintain corridor doors in compliance with NFPA 101 standards, as evidenced by observations made during a survey. Specifically, four out of more than 40 corridor doors inspected did not close and latch properly. This deficiency was identified during an inspection on March 19, 2025, when surveyors observed that the doors to resident rooms 124, 125, and 134 did not close and latch when tested. The deficiency was confirmed through an interview with the Facility Administrator, Maintenance Personnel, and the Plant Operations Director on the same day. The report highlights that the corridor doors are required to resist the passage of smoke and have positive latching hardware, which was not met in these instances. The failure to maintain these doors could potentially compromise the safety standards set for the facility.
Plan Of Correction
1. The doors of room 124, 125 and 134 had the hinges tightened and the transitions trips have been exchanged to ensure an easy closure of the door. 2. No other doors were identified as not latching. 3. The Director of Plant operations or designee will audit the latching of doors monthly x 3 months. 4. Audits will be taken to the safety committee and submitted to the QAPI committee for review of findings and further interventions are warranted.