Corridor Doors Failed to Latch Upon Closing
Penalty
Summary
Surveyors observed that the facility failed to maintain corridor doors in accordance with regulatory requirements. During a facility tour, it was found that the corridor door to the SNF Nurse Manager office and the corridor door to the storage room by resident room 732 did not latch upon self-closing. These doors are required to resist the passage of smoke and have positive latching hardware to ensure proper containment in the event of a fire. The deficiency affected 14 of 59 residents and one of four smoke compartments. During the interview, the Director of Subacute stated they were unaware that the doors did not latch. The report does not mention any specific medical history or condition of the residents involved at the time of the deficiency.
Plan Of Correction
The contracted company repaired the corridor door to the SNF nurse manager office and storage room by resident room 732. (Please see the attachment). MONITORING: 1. The plant operations team, headed by the Plant Operations Director or qualified designee, will be inspecting the doors on an annual basis. Additional monitoring will be conducted during Environment of Care (EOC) rounding on a quarterly basis. Action plans are generated with findings and deadlines for completion. Findings and data trends are reported to the environment of care committee on a quarterly basis for further review and recommendations.