Corridor Doors Fail to Resist Smoke Passage
Penalty
Summary
The facility failed to ensure that the corridor doors to resident rooms were maintained to resist the passage of smoke, as required by NFPA 101 standards. During a Life Safety Recertification Survey conducted on two consecutive days, it was observed that the corridor doors on all eight resident floors had openings between the two doors, which compromised their ability to resist smoke passage. This deficiency was confirmed through staff interviews, where the Director of Maintenance acknowledged the issue and indicated that astragals would be installed to address the problem.
Plan Of Correction
Plan of Correction: Approved February 3, 2025 K363 Corridor Doors 1. What Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: Astragals will be installed on the corridor doors to the resident suites to ensure they resist the passage of smoke. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: Astragals will be installed throughout the skilled nursing facility building on all the corridor doors to ensure they resist the passage of smoke. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: A follow-up inspection will be conducted by the Director of Maintenance to verify that the astragals have been installed and are functioning properly. The facility’s compliance will be monitored utilizing the following quality assurance system: Weekly rounds will be conducted to ensure the astragals have been installed and are functioning properly, and that all corridor doors are maintained to resist the passage of smoke in accordance with NFPA 101. The Maintenance and Fire Safety Staff were in-serviced on corridor doors installed to resist the passage of smoke, in accordance with NFPA 101. The Fire Safety Staff and Maintenance Staff will conduct weekly rounds confirming the corridor doors resist the passage of smoke. The Maintenance Staff will address any doors that are not compliant with the standard. 4. How the Corrective Action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice: The Director of Maintenance will gather information from the maintenance checks performed and report the findings to the QAPI committee for a period of 3 months or until compliance is achieved. 5. Responsible Individual: Director of Maintenance