Corridor Door Latching Deficiency
Penalty
Summary
The facility failed to maintain proper corridor door functionality in two specific locations on the second floor, which affected the safety measures required for smoke and fire resistance. During an observation conducted on April 21, 2025, it was noted that the door to the Activities room did not latch into the frame when tested. This failure to latch compromises the door's ability to resist the passage of smoke, which is a critical safety requirement in fully sprinklered smoke compartments. Additionally, the door to Resident room 223 also failed to latch into the frame when tested. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Manager. The inability of these doors to latch properly indicates a lapse in maintaining the required safety standards for corridor openings, which are essential for ensuring the safety and protection of residents and staff in the event of a fire or smoke emergency.
Plan Of Correction
1) 2nd floor Activities Door and Room 223 were fixed by Maintenance. 2) To identify other areas for potential concern, Maintenance Director/ designee quality monitored facility doors to ensure doors latched appropriately. Negative findings addressed. 3) To prevent this from recurring, NHA/designee re-educated Maintenance on corridor opening deficiencies. 4) To monitor and maintain compliance, Maintenance Director/ designee to quality monitor facility doors for opening deficiencies 1x weekly x 4 weeks then 2x monthly x 1 month. Findings will be forwarded to QA Committee for review and recommendation.