Noncompliant Corridor Door Hold-Open Device
Penalty
Summary
The facility failed to ensure that all corridor doors were able to resist the passage of smoke and were provided with a suitable means for keeping the doors closed, as required by NFPA 101-2012 and NFPA 80-2010 standards. During a facility tour, surveyors observed a 20-minute fire-rated double-corridor door being held open by an unapproved chain with a magnet attached. This setup was not compliant with regulations, as the magnet on the chain could interfere with the door's latching mechanism and was not an approved device for holding the door open. The magnet, when the door closed, would swing on its chain and potentially interfere with the door's ability to latch properly. This deficiency was confirmed through interviews with the Regional Maintenance Director and the Maintenance Director, who acknowledged the findings at the time of observation. The improper use of the chain and magnet did not meet the requirement for corridor doors to have positive latching hardware and to resist the passage of smoke. The report specifies that this deficiency had the potential to affect 13 out of 39 residents in the facility. No additional details about the specific residents or their medical conditions were provided in the report. The deficiency was limited to the improper securing of a fire-rated corridor door, which did not comply with the required fire and smoke protection standards.
Plan Of Correction
Tag: K 0363 Chain and magnet on double corridor door modified to keep from impeding closure on 6/20/25. No other fire rated or smoke barrier doors found to be impeded from closing appropriately. Administrator educated maintenance director on NFPA 101 corridor doors on 6/16/25. Maintenance director or designee will audit all corridor doors weekly x 4 weeks. Audit results will be submitted to the QAPI committee for review and recommendations.