Deficiencies in Corridor Door Maintenance
Penalty
Summary
The facility was found to have deficiencies related to the maintenance of corridor doors, which are crucial for fire safety and smoke containment. On March 31, 2025, an observation revealed that the stairtower doors on the 1st floor, near Resident Room 215, had gaps greater than the allowed 3/16 inch. This was confirmed by an interview with the Director of Maintenance, indicating that the doors exceeded the permissible gap margins, thus failing to meet the National Fire Protection Association (NFPA) 101 standards for corridor doors. Additionally, further observations on the same day revealed that the corridor doors to Resident Rooms 215 and 205 failed to close and latch properly. These findings were also confirmed through interviews with the Director of Maintenance. The inability of these doors to close and latch compromises their effectiveness in resisting the passage of smoke, which is a critical safety requirement, especially in fully sprinklered smoke compartments. These deficiencies highlight a failure in maintaining the required safety standards for corridor doors within the facility.
Plan Of Correction
1. The corridor doors to Resident Rooms 205 and 215 have been adjusted to close and latch. 2. The corrective action was completed on 4/1/2025. 3. The Maintenance Director or Designee will conduct a facility wide audit of all facility corridor doors for closure and latch then random door checks monthly. 4. Findings of Audits will be submitted to QAPI for review.