Failure to Maintain Properly Latching Corridor Doors
Penalty
Summary
Surveyors observed that the facility failed to maintain corridor doors in accordance with NFPA 101 and CMS regulations. Specifically, during an inspection on July 30, 2025, it was found that the door to Room 300 on the third floor and the door to Room 222 on the second floor did not latch when tested. These deficiencies were identified in two of the seven smoke compartments within the facility. The observations were confirmed through interviews with the Facility Administrator and Maintenance Director, who acknowledged the issues with the corridor doors. The report does not mention any specific residents affected or provide details about their medical history or condition at the time of the deficiency. The deficiency is limited to the failure of the doors to latch properly, as required for fire and smoke protection.
Plan Of Correction
On July 30, 2025, the Maintenance Director adjusted the Room 300 door and the Room 222 door and ensured the doors latched. The Nursing Home Administrator re-educated the Maintenance Director and maintenance assistant on the need to ensure all corridor doors latch properly. The maintenance staff will conduct a whole house audit to ensure all corridor doors in all smoke compartments latch properly. All corridor doors will be checked weekly during Interdisciplinary Team room rounds, and work orders will be submitted for any doors not latching properly. Room rounds reports are reviewed during morning meetings and submitted to the Safety Committee as appropriate for review.