Failure to Maintain Corridor Door Latching
Penalty
Summary
The facility failed to maintain a corridor opening as required by regulations, specifically concerning the doors in the Main dining room. During an observation on April 30, 2025, at 10:46 am, it was noted that the right set of double doors in the Main dining room did not positively latch into the frame. This deficiency affects one of the two floors in the facility. The issue was confirmed during an exit interview with the Facility Administrator and the Facilities Manager on the same day at 11:00 am. The failure of the doors to positively latch is a violation of the requirements for corridor doors, which are supposed to resist the passage of smoke and have positive latching hardware, especially in fully sprinklered smoke compartments.
Plan Of Correction
The main dining room right set of double doors' door assembly was adjusted to provide positive latching by facility maintenance department. The Maintenance Director/designee will conduct a facility wide audit of double doors to identify doors requiring adjustment to fully latch and coordinate repairs as identified. The Nursing home Administrator will provide re-education to the Maintenance Director on proper door latching requirement. The Maintenance Director will conduct audits on latching doors to verify compliance weekly x 4 weeks, then monthly x 2 months. The results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for compliance.