Failure to Maintain Smoke-Resistant Corridor Doors
Penalty
Summary
Surveyors observed that the facility failed to ensure that doors protecting corridor openings were capable of resisting the passage of smoke as required by NFPA 19.3.6.3. Specifically, on three separate occasions, it was found that the North Dining Room door across from resident room 125 was missing a latch and would not properly latch when tested, and the North Dining Room door across from resident room 107 also would not latch. Additionally, Resident Room 125 was found to have a 2-inch gap between the door and the floor, exceeding the maximum allowable clearance. These deficiencies were confirmed through direct observation and interview with the Facility Maintenance Director at the time of the survey. The report does not mention any specific residents' medical history or conditions at the time of the deficiency, nor does it indicate any immediate harm, but it documents the failure of the facility to maintain corridor doors in accordance with fire safety regulations.
Plan Of Correction
K363 1. The Maintenance Director and/or designee will repair the North Dining Room doors to ensure a positive latch, along with the gap in resident room 125 door. 2. The Administrator will review regulation K363 and provide education to the Maintenance team on the requirements. 3. The Maintenance Director and/or designee will conduct weekly rounds of doors protecting corridor openings to ensure no gaps and that doors close to a positive latch. Results of the audits will be brought to the Quality Assurance Performance Improvement meeting monthly for review. The Committee will be responsible for any changes to the auditing process. 4. The Administrator is responsible to attain and maintain compliance. Completion date for compliance will be 06.20.25.