Failure to Maintain Corridor Door Latching Hardware
Penalty
Summary
Surveyors observed that the facility failed to maintain resident room doors in good repair and free from impediments that prevent full closure. Specifically, during an observation outside Resident Room 18, it was noted that the positive latching hardware on the corridor door did not activate to keep the door shut. This issue was identified during a concurrent observation and interview with facility staff. The deficiency was found in one of three smoke compartments, where the malfunctioning latch could allow the door to remain open. The report documents that the door's inability to latch properly could compromise the intended function of the door in resisting the passage of smoke and fire, as required by regulation. No additional details about the residents' medical history or condition at the time of the deficiency are provided in the report.
Plan Of Correction
K 363 Corridor - Doors Correct Deficient Practice: On 03/10/2025 MS replaced malfunctioning latch that was preventing the fire door from latching shut when closed. Identify Others: All fire doors in the facility were inspected on 03/10/2025 by MS to ensure doors latch when closed. No other deficient practice found. Systemic Changes: In-service education was provided by Administrator on 03/10/2025 to Maintenance Supervisor regarding facility's policy and procedures titled "Fire Safety Inspections" and "Fire and Smoke Barrier Doors," indicating that fire and smoke barrier doors will automatically close when the fire alarm system is activated or power failure occurs. On 03/10/2025, Director of Staff Development provided in-service education to staff regarding facility policy and procedure titled, "Fire and Smoke Barrier Doors," indicating that staff are to report fire and smoke barrier doors that are partially open or that do not close properly in writing to the maintenance supervisor. Staff attending the in-service verbalized understanding. Monitoring: Findings and trends from inspection rounds will be brought to the Quarterly Safety Committee meeting by MS until the Safety Committee has determined compliance has been sustained. Facility's Safety Committee will provide further recommendations as necessary. Completion Date: 3/28/25 K 363