Deficiencies in Corridor Door Smoke Resistance
Penalty
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 soiled utility room door on the South unit of the Weinberg building did not latch when tested for self-closing. Additionally, the wheelchair storage room within the Rehab room lacked a self-closing device. Similar issues were noted with the corridor door to the oxygen storage room and the clean linen room in the nursing home on the SW 2 second floor. On a subsequent tour, the self-closing device to the soiled utility room on the third floor was found to be in disrepair, and the same issue was observed with the corridor door to the oxygen storage room on the South West 1 unit and the clean linen room on South West 2. These deficiencies were confirmed during an interview with the Director of Plant Operations.
Plan Of Correction
Plan of Correction: Approved February 21, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is: 1. The maintenance staff adjusted the door to the Weinberg building soiled utility room on the South unit. The corridor door self-closes and positive latches. 2. The maintenance staff installed a self-closing device to the wheelchair storage room within the Rehab room. The door self-closes and positive latches. 3. The maintenance staff adjusted the door to the Weinberg building oxygen storage room. The corridor door self-closes and positive latches. 4. The maintenance staff adjusted the door to the SW2 clean linen room. The corridor door self-closes and positive latches. 5. The maintenance staff replaced the self-closing devices on the door to the Nursing Home soiled utility room on the 3rd floor. The corridor door self-closes and positive latches. 6. The maintenance staff replaced the self-closing devices on the door to the Nursing Home oxygen storage room on SW1. The corridor door self-closes and positive latches. 7. The maintenance staff replaced the self-closing devices on the door to the Nursing Home clean linen room on SW2. The corridor door self-closes and positive latches. 2. How will The New Jewish Home (NAME) Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above)? The facility acknowledges that all residents have the potential to be affected by this practice. The Director of Maintenance inspected all areas throughout the facility for same deficiencies. No other deficiencies were identified. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur? All maintenance staff will receive additional education and all participants will understand the life safety issues identified, with the protection of Hazardous Areas – Enclosure in accordance with NFPA [PHONE NUMBER]: 19.3.1.1. The Director of Maintenance has been assigned the responsibility for the education of staff and report the findings to the QAPI Committee for the period of six (6) months. The facility will check hazardous area enclosure doors self-close and positive latch monthly. The Director of Maintenance will complete documentation in an audit tool and report the findings to the QAPI Committee monthly for a period of six (6) months. 4. How will The New Jewish Home (NAME) Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor the continued effectiveness of the systemic change)? The Director of Maintenance or Designee will review monthly audits for any cases of non-compliance. The Director of Maintenance or Designee will report the result of these audits to the QAPI committee on a monthly basis, as well as correction plan if warranted.