Corridor Door Deficiencies in Smoke Compartments
Penalty
Summary
The facility failed to maintain corridor doors in compliance with NFPA 101 standards, as observed during a survey on April 22, 2025. Specifically, two corridor doors in different smoke compartments were found to be deficient. At 10:58 a.m., the door to Room 23B in the Overly Wing was observed to not close and latch properly in its frame. Similarly, at 11:35 a.m., the door to Room 10B in the Shimer Wing also failed to close and latch in its frame. These deficiencies were confirmed during an interview with the Facility Administrator and Plant Operations Manager on the same day at 2:00 p.m. The inability of these doors to close and latch properly compromises their ability to resist the passage of smoke, which is a critical safety requirement in maintaining the integrity of smoke compartments within the facility.
Plan Of Correction
1. Facility maintenance staff fixed latch on doors to resident rooms 23B and 10B and ensured doors closed and latched on 4/30/2025. 2. Monthly door inspection form was created and provided to Plant Operations manager on 05/06/2025. 3. Facility maintenance staff will begin documenting monthly fire door inspections of all fire doors on both corridors by 5/23/2025. 4. Completion of inspections and corresponding documentation will be audited at the Building and Safety Meeting attended by The Plant Operations Manager, Director of Environmental Services, FCMC Safety Officer, Nursing Home Administrator and Chief Operations Officer for six months.