Deficiency in Corridor Door Smoke Resistance
Penalty
Summary
The facility failed to ensure that all corridor doors were designed to resist the passage of smoke, as required by the 2012 NFPA 101 standards. During a life safety survey, it was observed that the doors to the clinical social worker's office and the medical equipment storage closet were equipped with transfer grilles at the bottom, which is not permitted. Additionally, a large storage room on the first floor near the garage entrance was found to be lacking a door entirely. These deficiencies were noted on the first and third floors of the facility, and the Director of Maintenance acknowledged the issues during the survey.
Plan Of Correction
Plan of Correction: Approved April 17, 2025 K 353- Sprinkler System- Maintenance and Testing I. IMMEDIATE CORRECTIVE ACTION The 5-year internal pipe inspection of the sprinkler system was immediately scheduled with our vendor Sprinkler Company. The Maintenance Staff were educated to ensure that all required testing, inspection and maintenance was conducted on the facility's automatic sprinkler system. II. IDENTIFICATION OF OTHERS AFFECTED: All residents have the potential to be affected. In order to ensure full compliance of this standard throughout this facility, the Director of Maintenance will review any additional required Automatic Sprinkler Testing to ensure it too meets all aspects of the NFPA Standard. All other Maintenance and Testing current and up to date. III. SYSTEMIC CHANGES: A monthly compliance audit will be completed to ensure that all required Sprinkler Maintenance and Testing are done. This audit will begin (MONTH) 2025 and continue for a period of 12 months. Any negative findings will be immediately reported to facility administrator and corrected. IV. QAPI MONITORING: The findings of the audit will be reported to the facility Quality Assurance and Performance Improvement Committee for 3 months by the Director of Maintenance. Any trends or concerns that may be identified will be discussed by the committee and any necessary interventions will be implemented. The QAPI Committee will determine the need for ongoing reporting. Completion date: 05/30/2025 Responsible Party: Director of Maintenance