Corridor Door Closure Deficiency
Penalty
Summary
The facility failed to maintain their corridor doors in accordance with NFPA 101 standards. During a facility tour conducted on March 17, 2025, between 11:30 AM and 2:30 PM, it was observed that the patient room corridor door to room 47 would not completely close. This issue was caused by the bottom of the door rubbing against the floor, which prevented the door from closing properly. This deficiency was identified during observations made by the surveyors in the presence of the Maintenance Director. The findings were confirmed through an interview with the Maintenance Director, who was present during the observations. The issue was further discussed and reviewed at an exit conference with the administrator and the Maintenance Director on the same day at 3:00 PM. The deficiency was noted as a failure to comply with the requirements set forth in NFPA 101 (2012 and 2021 editions) and NFPA 80 (2010 and 2019 editions), which specify the standards for corridor doors to resist the passage of smoke and ensure proper closure.
Plan Of Correction
1. The resident room corridor door to room 47 was repaired to properly close. 2. Additional resident room corridor doors will be reviewed for proper closing. 3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Corridor- Doors specific to maintaining resident room corridor doors to properly close and will continue to monitor in accordance with NFPA standards. 4. Any findings will be reported to the monthly QAPI Committee for further review.