Deficient Corridor Door Smoke Resistance
Penalty
Summary
The facility failed to ensure that corridor doors were able to resist the passage of smoke as required by NFPA 101: 2012 Edition. During a survey conducted on December 4, 2024, it was observed that the double doors between the West wing and the Main dining room had a gap between the meeting edges. Additionally, the door to room #9 had a gap on top. These deficiencies were identified during a tour conducted from 8:15 AM to 3:45 PM. The surveyor confirmed these observations through interviews conducted at the time of the inspection. The facility's representative was notified of these deficiencies during the Life Safety Code Survey exit conference on December 5, 2024. The failure to maintain corridor doors that resist the passage of smoke had the potential to affect all 83 residents in the facility.
Plan Of Correction
Rose Mountain Care Center Facility ID: 3145384 Survey completion date: 12-12-2024 K363 - (F) Corridor - Doors Element One: The gap on the double doors between the west wing and the dining room was immediately sealed leaving no room for smoke to pass through. The gap on door room #9 was immediately sealed. Element Two: This deficient practice had the potential to affect all 83 residents. Element Three: The U.S. FOIA (b) (6) was educated on the requirements related to corridor doors resisting the passage of smoke. Element Four: The maintenance director / designee will audit the above findings monthly x3 ensuring the doors are able to resist the passage of smoke. Results will be reported to the QAPI team for review.