Non-Latching Corridor Doors Compromising Smoke Compartment Integrity
Penalty
Summary
Surveyors observed that the facility failed to maintain corridor doors in accordance with regulatory requirements. Specifically, during a facility tour, two corridor doors—one to the Shower Room by Room 6 and another to the Salon by Room 13—were found to have self-closing mechanisms but did not latch when tested for closure. Each door was tested approximately three times and failed to latch on each attempt. Staff interviews indicated that the Shower Room door may have required lubrication, while the Salon door's failure to latch was attributed to air pressure in the room. This deficiency affected 34 of 92 residents and two of six smoke compartments within the facility. The non-latching doors could allow the passage of smoke between compartments, as the doors did not resist the passage of smoke as required. No specific resident medical histories or conditions at the time of the deficiency were mentioned in the report.
Plan Of Correction
K 363 - Corridor Doors How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: • Maintenance staff lubricated and adjusted the self-closing mechanisms on the Shower Room door by Room 6 and the Salon door by Room 13 to ensure proper latching. • The EVS Director replaced both door handles on 4/10/25 to ensure proper latching. • Both doors were tested three times and successfully latched upon closure. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: • No additional residents have the potential to be affected. This latching concern only affects the two smoke compartments and cannot affect the other smoke compartments. • On 4/10/25 a facility-wide inspection was conducted to identify any other door latching issues. No other issues were found. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: • On 4/10/25 a facility-wide inspection was conducted to identify any other door latching issues. No other issues were found. • The maintenance team has implemented a monthly inspection schedule to ensure all corridor doors latch properly and self-closing mechanisms function as required. • The EVS Director was trained by the Administrator on the importance of proper door maintenance, including lubrication, alignment, and troubleshooting air pressure issues that may affect door closure. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: • The maintenance team has implemented a monthly inspection schedule to ensure all corridor doors latch properly and self-closing mechanisms function as required. • Results will be reviewed in the QAPI meetings for ongoing compliance oversight. Date of Compliance 4/18/25