Failure to Maintain and Inspect Fire and Smoke Door Assemblies
Summary
The facility failed to provide regular inspections, testing, and maintenance of fire and smoke door assemblies as required by NFPA 80 and NFPA 105. During a record review with the Administrator and Maintenance Director, the facility was unable to produce documentation of annual inspections for smoke doors or evidence of training for a competent, certified individual responsible for fire and smoke doors. This lack of documentation and training was confirmed during interviews with facility leadership. The deficiency was acknowledged by both the Administrator and the Maintenance Director during the exit conference. No information was provided regarding specific residents or patient conditions related to this deficiency. The report focuses solely on the absence of required inspection records and training for fire and smoke door assemblies.
Penalty
Surveyors identified several corridor door deficiencies, including doors that failed to latch, lacked smoke tight integrity, and had missing locksets, across multiple floors. These issues were confirmed by facility leadership during the exit conference.
Surveyors found that two corridor doors, one on the third floor and one on the second floor, did not latch when tested, affecting two smoke compartments. The Facility Administrator and Maintenance Director confirmed these deficiencies, which were not in compliance with fire and smoke protection requirements.
A corridor door leading to the Patio Lounge failed to positively latch within the door frame, as observed and confirmed by the Director of Maintenance. This deficiency affected one of twelve smoke compartments and did not meet NFPA 101 and CMS requirements for corridor door latching.
Surveyors found that corridor doors to two resident rooms did not close and latch properly, as confirmed by the facility's Administrator and Maintenance Director. This deficiency affected one of five smoke compartments and did not meet regulatory requirements for smoke resistance and positive latching.
Two corridor doors, serving resident rooms in a smoke compartment, were found to be stuck in their frames and unable to fully latch, as confirmed by facility leadership during the survey.
Surveyors found that two resident rooms had wooden door wedges holding corridor doors open, preventing them from closing as required for fire safety. Facility staff confirmed that the wedges impeded proper door closure.
Multiple Corridor Door Deficiencies Impacting Smoke and Fire Protection
Penalty
Summary
Surveyors observed multiple deficiencies related to corridor doors on three of four floors within the facility. Specifically, one door on the 3rd floor (Room 315) failed to latch properly in its frame. On the 2nd floor, Room 220's door did not maintain smoke tight integrity even when latched, and the Clean Utility door near the Nurses' Station had an open hole where the lockset was removed. On the 1st floor, doors to Rooms 128 and 107 also lacked smoke tight integrity while latched in their frames. These deficiencies were confirmed during an exit conference with facility leadership, including the Administrator, Regional Director, Regional Maintenance Director, and Environmental Services Director. The report does not mention any specific residents or their medical conditions in relation to these deficiencies.
Plan Of Correction
The facility failed to maintain corridor doors on three of four floors. No residents were affected. All residents have the potential to be affected. The corridor door on the 3rd floor, Room 315 was repaired to meet the regulation and latch in the corresponding frame. The corridor door on the 2nd floor, Room 220 was repaired to ensure smoke tight integrity. The 2nd floor, the hole noted in the clean utility door near the nurses' station was repaired. The corridor door on the 1st floor, Room 128 was repaired to ensure smoke tight integrity. The corridor door on the 1st floor, Room 107 was repaired to ensure smoke tight integrity. An audit of the facility's remaining resident corridor doors was completed by the Director of Maintenance to ensure that all doors meet the requirement. Director of Maintenance and maintenance staff were educated by the Administrator on maintaining corridor doors to meet the requirement of smoke tight integrity and latch properly. The Maintenance Director/Designee will conduct one weekly audit of corridor doors to check function and integrity for four weeks. The audits will continue monthly thereafter. Results of audits will be reviewed at the Quarterly Quality Assurance and Improvement Committee Meeting over the duration of the audit process. Based on the results of the audits, a decision will be made regarding the need for continued submission and reporting.
Failure to Maintain Properly Latching Corridor Doors
Penalty
Summary
Surveyors observed that the facility failed to maintain corridor doors in accordance with NFPA 101 and CMS regulations. Specifically, during an inspection on July 30, 2025, it was found that the door to Room 300 on the third floor and the door to Room 222 on the second floor did not latch when tested. These deficiencies were identified in two of the seven smoke compartments within the facility. The observations were confirmed through interviews with the Facility Administrator and Maintenance Director, who acknowledged the issues with the corridor doors. The report does not mention any specific residents affected or provide details about their medical history or condition at the time of the deficiency. The deficiency is limited to the failure of the doors to latch properly, as required for fire and smoke protection.
Plan Of Correction
On July 30, 2025, the Maintenance Director adjusted the Room 300 door and the Room 222 door and ensured the doors latched. The Nursing Home Administrator re-educated the Maintenance Director and maintenance assistant on the need to ensure all corridor doors latch properly. The maintenance staff will conduct a whole house audit to ensure all corridor doors in all smoke compartments latch properly. All corridor doors will be checked weekly during Interdisciplinary Team room rounds, and work orders will be submitted for any doors not latching properly. Room rounds reports are reviewed during morning meetings and submitted to the Safety Committee as appropriate for review.
Failure to Maintain Positive Latching of Corridor Door
Penalty
Summary
The facility failed to maintain the positive latching of a corridor door, specifically the Zone 8 door to the Patio Lounge. During an observation, it was found that this door did not positively latch within the door frame as required by NFPA 101 and CMS regulations. The deficiency was identified during a survey, and the issue was confirmed through an interview with the Director of Maintenance, who acknowledged that the corridor door failed to latch properly. This deficiency affected one of twelve smoke compartments within the facility. The report does not mention any specific residents or patients involved, nor does it provide details about their medical history or condition at the time of the deficiency. The focus of the finding is solely on the failure of the door to meet the required positive latching standard, as observed and confirmed by facility staff.
Plan Of Correction
The Zone 8 patio lounge door has been adjusted to latch positively. Maintenance staff will be educated on ensuring all doors latch positively moving forward. Maintenance Director/Designee to perform an audit on doors latching positively weekly for 4 weeks and monthly for 2 months to ensure doors in the facility are latching properly. Results of audits will be forwarded to the QAPI Committee. The Zone 8 patio lounge door has been adjusted to latch positively. Maintenance staff will be educated on ensuring all doors latch positively moving forward. Maintenance Director/Designee to perform an audit on doors latching positively weekly for 4 weeks and monthly for 2 months to ensure doors in the facility are latching properly. Results of audits will be forwarded to the QAPI Committee.
Failure to Maintain Corridor Doors for Smoke Resistance and Latching
Penalty
Summary
Surveyors observed that the facility failed to maintain corridor doors in accordance with NFPA 101 requirements in two separate instances. During inspections, it was found that the door to resident room 140 and the door to resident room 109 would not close and latch properly in their frames when tested. These deficiencies were identified during routine observations on July 7, 2025, at different times in the morning. Interviews conducted with the Facility Administrator and the Maintenance Director confirmed the issues with the corridor doors. The deficiencies affected one of five smoke compartments in the facility, as the doors did not meet the required standards for resisting the passage of smoke and ensuring positive latching, as specified by regulatory guidelines.
Plan Of Correction
Resident room 140 door now closes and latches in its frame when tested, maintaining corridor doors and all five smoke compartments within the facility. The Maintenance Director/designee will ensure corridor doors close and latch into their frames monthly times three months. Findings will be reviewed at monthly Quality Assurance Meetings. Resident room 109 door now closes and latches in its frame when tested, maintaining corridor doors and all five smoke compartments within the facility. The Maintenance Director/designee will ensure corridor doors close and latch into their frames monthly times three months. Findings will be reviewed at monthly Quality Assurance Meetings.
Corridor Doors Failed to Latch in Smoke Compartment
Penalty
Summary
Surveyors observed that two corridor doors, specifically those to Resident Room 217 and Resident Room 223, were not functioning as required. During an inspection, it was found that these doors were getting stuck in their frames, which prevented them from fully latching. This issue was directly observed between 10:56 am and 10:57 am on June 30, 2025. At the exit conference, both the Administrator and the Director of Maintenance confirmed that the doors failed to positively latch into their frames. The deficiency was limited to these two doors within one of six smoke compartments in the facility. No additional information about the residents in these rooms or their medical conditions was provided in the report.
Plan Of Correction
Maintenance has repaired the doors to rooms 217 and 223 to ensure that they latch appropriately. NHA to re-educate facility Maintenance Director on proper latching of corridor doors. A full house audit completed by maintenance to ensure that corridor doors were not getting stuck in their corresponding frames to prevent them from fully latching. Maintenance will conduct weekly audits x 4 weeks and monthly audits x 2 months to ensure doors latch appropriately. Audits to be submitted to QAPI for review and recommendations.
Corridor Doors Blocked Open with Wedges
Penalty
Summary
Surveyors observed that the facility failed to maintain corridor doors in accordance with fire safety regulations on two of four levels. Specifically, during an inspection, it was found that a resident room on the fourth floor and another on the second floor each had a wooden door wedge holding the door open. These wedges prevented the doors from closing as required to resist the passage of smoke and maintain corridor safety. The Maintenance Supervisor and Director of Safety/Security confirmed during an exit interview that the use of door wedges inhibited the proper closing of the doors. The deficiency was identified through direct observation and staff confirmation, with no mention of any specific resident conditions or medical histories related to the incident.
Plan Of Correction
Door stops have been removed from doors. All other rooms checked for door stops and none noted. Staff will be educated to not use door stops. Residents and families will be educated upon admission that door stops cannot be used, and current residents will be educated regarding door stops at the next resident council meeting. The resident welcome book has been updated to include education regarding door stops and will be distributed to all residents upon admission and to all current residents.
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