Failure to Maintain Corridor Doors with Positive Latching
Penalty
Summary
Surveyors observed that the facility failed to maintain corridor doors in a manner that ensured they positively latched, as required by NFPA 101 and CMS regulations. Specifically, during an inspection, it was found that the door to the Kitchen near the 2nd floor Dining Room was impeded from closing properly due to a fatigue mat. Additionally, the double doors to the Linen Closet (2E66) had an inactive door that was not latched, and the PC Unit Office (1C06) door was hitting the frame, preventing it from latching. These issues were identified in three out of ten smoke compartments within the facility. The Director of Facilities confirmed during an interview that the corridor doors in these locations failed to positively latch. The report does not mention any specific residents or their medical conditions in relation to these deficiencies. The findings are based solely on direct observation and staff interview, with no mention of corrective actions or follow-up steps taken at the time of the survey.
Plan Of Correction
1. The fatigue mat located at the ice machine in the main kitchen will be reduced in size to prevent interference with the door. A recurring work order will be created to inspect this area for an impediment to the door quarterly for one year. Documentation will be presented to QAPI for evaluation. 2. An automatic bolt assembly and spring-loaded hinges will be installed to the Ellison linen closet right side door 2E66. A recurring work order will be created to inspect the door for automatic positive latching quarterly for one year. Completed work order documentation will be presented to QAPI for evaluation. 3. Shims will be removed from door 1C06 to prevent the door from hitting the frame. A recurring work order will be created to inspect the door for positive latching and gap margins quarterly for one year. Completed work order documentation will be presented to QAPI for evaluation.