Corridor Door Fails to Fully Close, Creating Gap in Smoke Compartment
Penalty
Summary
During a facility tour, surveyors observed that the door to the small dining room, when closed, left an approximately one-half inch gap between the door leaf and the doorframe. This observation was made in the presence of the Maintenance Consultant, who attributed the gap to the continual shifting of the building structure. The report specifies that this issue affected one of two smoke compartments in the facility. The deficiency was identified as a failure to maintain corridor doors in accordance with NFPA 101: Life Safety Code requirements. Specifically, the door did not fully close, which could delay the prevention of smoke spread during an emergency. The report does not mention any residents or staff being directly involved or affected at the time of the observation, nor does it provide any additional medical history or conditions related to individuals.
Plan Of Correction
NFPA 101 Life Safety Code Standards K 363 Corridor- Doors The corridor doors were adjusted and the gaps were fixed (See attached photos). The Director of Maintenance will audit the corridor doors weekly, ensuring that the fire doors are free of gaps and close completely for the next 3 months. The Administrator will review the audits and bring findings to the Quality Assurance Team on a quarterly basis to evaluate the effectiveness of the program. This corrective action was completed June 20th, 2025.