Deficiency in Corridor Door Smoke Resistance
Summary
The facility failed to ensure that corridor doors to hazardous areas were able to resist the passage of smoke as required by NFPA 101 standards. During a Life Safety recertification survey, it was observed that the kitchen storage room opposite the kitchen and the storage room within the kitchen did not latch when tested to self-close. Additionally, the storage room within the shower enclosure was missing a door knob and latching mechanism, preventing it from latching properly. These deficiencies were noted on one of the two resident floors. The Director of Maintenance acknowledged the issue during an interview conducted at the time of the findings.
Plan Of Correction
Plan of Correction: Approved February 28, 2025 All residents, visitors, and staff have the potential to be affected by the deficient practice. On 2/12/2025, the Director of Environmental Services or Designee adjusted the self-closing mechanisms on 2 of the 3 doors cited in order for the doors to positive latch as per NFPA 101. The Director of Environmental Services or Designee installed the new hardware (doorknob) on the 3rd of 3 doors for the storage room within the shower enclosure to ensure it has a positive latch. On 2/12/2025, the Director of Environmental Services or Designee conducted an audit of all dietary closets with self-closing mechanisms as well as the doors to all 4 storage rooms in the shower enclosures (1 on each unit) to ensure all are in working order as per NFPA 101. Those found deficient will be repaired. On 2/14/2025, the Director of Environmental Services or Designee will educate all maintenance staff on how to properly check doors for positive latch. Starting on 2/14/2025, the Director of Environmental Services or Designee will audit the 3 doors that did not self-latch weekly for 1 month (4 weeks) then monthly for 3 months to ensure the doors are self-latching. All findings will be repaired and reported in QAPI. Responsible party: Director of Environmental Services or designee.
Penalty
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.