Failure of Corridor Doors to Achieve Positive Latch
Penalty
Summary
Surveyors observed that the facility failed to ensure that doors protecting corridor openings were capable of resisting the passage of smoke as required by NFPA 19.3.6.3. Specifically, during an inspection, it was found that the vestibule doors leading to the courtyard from both the 500 and 600 wings did not close to a positive latch. This deficiency was identified through direct observation between 1:29 PM and 1:52 PM on May 19, 2025. The Maintenance Director confirmed at the time of discovery that the vestibule doors did not meet the required standard for positive latching. The report does not mention any specific residents or their medical conditions in relation to this deficiency. The finding was limited to the physical condition and operation of the doors in the specified wings.
Plan Of Correction
Element 1: Doors to the courtyard from the 500 and 600 wings failed to close a positive latch. Physical plant manager contacted multiple vendors and latching hardware will be installed. Element 2: This deficient practice has the potential to impact all occupants of the 500 and 600 wings in the event of a fire. Element 3: Superiorland Electronics will install latching hardware by 07/16/2025. Element 4: Physical Plant Manager will be responsible for sustained compliance. Audits will be done monthly and brought to QAPI.