Corridor Door Obstructed by Floor Mat
Penalty
Summary
During a facility tour, surveyors observed that the corridor door to resident room 507 was obstructed by a brown floor mat placed by bed A. This obstruction prevented the door from closing properly. The presence of the mat was confirmed during an interview with a staff member, who acknowledged that the door mat was in the way. This deficiency affected 23 out of 103 residents and one of five smoke compartments in the facility. The failure to maintain the corridor doors in accordance with regulatory requirements was specifically evidenced by the inability of the door to close due to the obstruction, as directly observed and confirmed by staff.
Plan Of Correction
K 363 and/or findings shall be reported by the Maintenance Director to the Quality Assurance and Performance Improvement Committee monthly for integration and recommendations. K 363: How will the corrective action be accomplished for those residents found to have been affected by the deficient practice? The mat that prevented the door of room 507 from closing was immediately relocated by the Maintenance Lead to allow the door to fully close. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility did not identify any other residents affected by the deficient practice but recognizes any resident in the first bed of the room with a floor mat has the potential to be affected by this same deficient practice. On 3/26/2025, all residents with floor mats were identified and all rooms were inspected to ensure that none of those mats impeded or obstructed the door from closing. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur? An in-service by the Director of Staff Development was held for all staff about ensuring that nothing, including floor mats, can prevent the resident room door from closing. The facility's Maintenance Director added a monthly corridor door inspection task to the TELS system, so the maintenance department is instructed to inspect all corridor doors monthly for proper closing and to ensure they are free from obstruction. Any findings shall be corrected immediately. NEXT PAGE INTENTIONALLY BLANK DUE TO FORMATTING. THIS PAGE INTENTIONALLY LEFT BLANK DUE TO FORMATTING. How does the facility plan to monitor its performance to make sure that the corrections are implemented and achieved, the solutions are sustained, and that the corrective actions taken are evaluated for effectiveness through integration into the facility's Quality Assurance system? The Facilities Maintenance Director will review the monthly corridor door inspection reports in TELS and report compliance and any findings to the Quality Assurance Committee monthly for integration and recommendations.