Failure to Maintain Positive Latching of Corridor Door
Penalty
Summary
The facility failed to maintain the positive latching of a corridor door, specifically the Zone 8 door to the Patio Lounge. During an observation, it was found that this door did not positively latch within the door frame as required by NFPA 101 and CMS regulations. The deficiency was identified during a survey, and the issue was confirmed through an interview with the Director of Maintenance, who acknowledged that the corridor door failed to latch properly. This deficiency affected one of twelve smoke compartments within the facility. The report does not mention any specific residents or patients involved, nor does it provide details about their medical history or condition at the time of the deficiency. The focus of the finding is solely on the failure of the door to meet the required positive latching standard, as observed and confirmed by facility staff.
Plan Of Correction
The Zone 8 patio lounge door has been adjusted to latch positively. Maintenance staff will be educated on ensuring all doors latch positively moving forward. Maintenance Director/Designee to perform an audit on doors latching positively weekly for 4 weeks and monthly for 2 months to ensure doors in the facility are latching properly. Results of audits will be forwarded to the QAPI Committee. The Zone 8 patio lounge door has been adjusted to latch positively. Maintenance staff will be educated on ensuring all doors latch positively moving forward. Maintenance Director/Designee to perform an audit on doors latching positively weekly for 4 weeks and monthly for 2 months to ensure doors in the facility are latching properly. Results of audits will be forwarded to the QAPI Committee.