Fire-Rated Corridor Doors Failed to Close Fully
Penalty
Summary
Surveyors observed that the fire-rated cross corridor doors between the main lobby and the main corridor hallway did not fully close, which compromised their ability to resist the passage of smoke and fire. This observation was made during a facility inspection and was confirmed through an interview with the maintenance director at the time of the survey. The doors in question are required by regulation to resist the passage of smoke and, in certain cases, fire, to prevent the spread of hazardous conditions between compartments. The deficiency was specifically noted as affecting the protection of corridor openings, as the doors failed to meet the standards outlined in NFPA 19.3.6.3. The report states that this issue could impact up to 50 occupants in the event of a smoke or fire event, as the compromised doors would allow heat, smoke, and fire to pass into adjacent compartments. No information about individual residents' medical histories or conditions at the time of the deficiency was provided in the report.
Plan Of Correction
Element 1 On May 14, 2025, maintenance personnel adjusted and repaired the door to Room 302 to ensure full closure and smoke resistance. A door sweep was installed on the door near Room 410 to eliminate the excessive gap. Element 2 A facility-wide audit of all corridor doors was completed on May 9, 2025. No other deficiencies in corridor door function were identified. All residents in proximity to the affected rooms were found safe and unaffected. Element 3 All facility doors were checked for compliance with smoke resistance standards on May 14, 2025. Staff were educated on May 16, 2025, on reporting improperly closing doors to the maintenance department immediately. Element 4 The Director of Maintenance or designee will complete monthly corridor door inspections to ensure doors close and latch properly and resist the passage of smoke. Results will be recorded and reviewed during QAPI meetings. Any failure will prompt immediate repair and re-education. The administrator is responsible for the sustained compliance.