Failure to Maintain Corridor Doors for Smoke Resistance and Latching
Penalty
Summary
Surveyors observed that the facility failed to maintain corridor doors in accordance with NFPA 101 requirements in two separate instances. During inspections, it was found that the door to resident room 140 and the door to resident room 109 would not close and latch properly in their frames when tested. These deficiencies were identified during routine observations on July 7, 2025, at different times in the morning. Interviews conducted with the Facility Administrator and the Maintenance Director confirmed the issues with the corridor doors. The deficiencies affected one of five smoke compartments in the facility, as the doors did not meet the required standards for resisting the passage of smoke and ensuring positive latching, as specified by regulatory guidelines.
Plan Of Correction
Resident room 140 door now closes and latches in its frame when tested, maintaining corridor doors and all five smoke compartments within the facility. The Maintenance Director/designee will ensure corridor doors close and latch into their frames monthly times three months. Findings will be reviewed at monthly Quality Assurance Meetings. Resident room 109 door now closes and latches in its frame when tested, maintaining corridor doors and all five smoke compartments within the facility. The Maintenance Director/designee will ensure corridor doors close and latch into their frames monthly times three months. Findings will be reviewed at monthly Quality Assurance Meetings.