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.