Deficiency in Corridor Door Smoke Resistance
Penalty
Summary
During an inspection, it was observed that the door handle of the medication supply room had a gap measuring approximately 2 inches long by 1/4 inch wide at the handle cover. This gap was identified during a walkthrough and was confirmed by the facility's maintenance staff at the time of observation. The deficiency pertains to the requirement that doors protecting corridor openings must be capable of resisting the passage of smoke, as outlined in NFPA 19.3.6.3. The presence of the gap in the door handle area means the door does not meet the standard for smoke resistance, which could affect the safety of up to 20 occupants in the event of a fire emergency.
Plan Of Correction
K 363: The med supply door handle was corrected related to a gap that would allow smoke to pass and addressed to remedy this concern. Like areas were reviewed for areas of concern with no concerns noted at this time. Maintenance Director was educated on K363. Tag to ensure corridors openings are capable of resisting the passage of smoke. Maintenance Director will complete facility rounds to ensure concerns observed will be addressed at the time of observation. Results of audits will be reported to QAPI Monthly x3 and PRN. Administrator is responsible for maintaining compliance.