Deficiencies in Door Maintenance Affecting Smoke Compartments
Summary
The facility was found to have deficiencies in maintaining hazardous area enclosures and corridor openings, affecting smoke compartments. On December 30, 2024, an observation revealed that the door to the Soiled Utility Room on the second floor was not smoke-tight, which is a requirement for hazardous area enclosures. This deficiency was confirmed during an exit interview with the Facility Administrator. Additionally, another deficiency was noted on the same day when the first-floor Dietary door failed to close and latch properly due to door drag. This issue was also confirmed during the exit interview with the Facility Administrator. Both deficiencies indicate a failure to comply with the requirements for doors protecting corridor openings, which are essential for resisting the passage of smoke and ensuring safety in the event of a fire.
Plan Of Correction
1. Door will be replaced so it will close and latch properly. 2. Other doors enclosures will be checked to verify closing and latching. 3. Maintenance will be re-educated on ensuring that all door enclosures are closing and latching. 4. Maintenance Director/ designee will conduct random audits to verify that door enclosures are closing and latching weekly for 4 weeks and then monthly for 2 months thereafter. Audits results will be presented at the QAPI meeting for review and recommendations.
Penalty
Surveyors found that a corridor door to a resident room on one floor failed to latch into the frame when tested, meaning it did not meet NFPA 101 requirements for positive latching of corridor doors. The Facilities Manager and Facility Life Safety staff confirmed during interview that this corridor door did not latch properly.
Surveyors identified several corridor door deficiencies, including doors that failed to latch, lacked smoke tight integrity, and had missing locksets, across multiple floors. These issues were confirmed by facility leadership during the exit conference.
Surveyors found that two corridor doors, one on the third floor and one on the second floor, did not latch when tested, affecting two smoke compartments. The Facility Administrator and Maintenance Director confirmed these deficiencies, which were not in compliance with fire and smoke protection requirements.
A corridor door leading to the Patio Lounge failed to positively latch within the door frame, as observed and confirmed by the Director of Maintenance. This deficiency affected one of twelve smoke compartments and did not meet NFPA 101 and CMS requirements for corridor door latching.
Surveyors found that corridor doors to two resident rooms did not close and latch properly, as confirmed by the facility's Administrator and Maintenance Director. This deficiency affected one of five smoke compartments and did not meet regulatory requirements for smoke resistance and positive latching.
Two corridor doors, serving resident rooms in a smoke compartment, were found to be stuck in their frames and unable to fully latch, as confirmed by facility leadership during the survey.
Failure of Corridor Door to Latch Properly
Penalty
Summary
Surveyors identified a deficiency involving a corridor door that did not meet NFPA 101 requirements for positive latching. During observation on the second floor B-Hall, the door to Resident Room 209 was tested and found to fail to latch into the door frame. This condition was noted as a failure to maintain a corridor opening in accordance with the requirement that corridor doors resist the passage of smoke and have positive latching hardware. The issue was observed on one of four floors in the building and specifically involved the corridor door to a resident room. At the time of the survey, the door did not properly engage with the frame when tested, meaning it did not latch as required. During the exit interview, the Facilities Manager and Facility Life Safety staff confirmed that the corridor door to Resident Room 209 failed to latch.
Plan Of Correction
Room 209 door was immediately adjusted to insure proper closure. Resident room doors were inspected and adjusted. Random audits of resident room door closure will be conducted on 5 doors on each nursing unit weekly for 8 weeks. Corridor doors will be inspected semi-annually for proper closure. Any doors found to be not closing properly are adjusted or replaced.
Multiple Corridor Door Deficiencies Impacting Smoke and Fire Protection
Penalty
Summary
Surveyors observed multiple deficiencies related to corridor doors on three of four floors within the facility. Specifically, one door on the 3rd floor (Room 315) failed to latch properly in its frame. On the 2nd floor, Room 220's door did not maintain smoke tight integrity even when latched, and the Clean Utility door near the Nurses' Station had an open hole where the lockset was removed. On the 1st floor, doors to Rooms 128 and 107 also lacked smoke tight integrity while latched in their frames. These deficiencies were confirmed during an exit conference with facility leadership, including the Administrator, Regional Director, Regional Maintenance Director, and Environmental Services Director. The report does not mention any specific residents or their medical conditions in relation to these deficiencies.
Plan Of Correction
The facility failed to maintain corridor doors on three of four floors. No residents were affected. All residents have the potential to be affected. The corridor door on the 3rd floor, Room 315 was repaired to meet the regulation and latch in the corresponding frame. The corridor door on the 2nd floor, Room 220 was repaired to ensure smoke tight integrity. The 2nd floor, the hole noted in the clean utility door near the nurses' station was repaired. The corridor door on the 1st floor, Room 128 was repaired to ensure smoke tight integrity. The corridor door on the 1st floor, Room 107 was repaired to ensure smoke tight integrity. An audit of the facility's remaining resident corridor doors was completed by the Director of Maintenance to ensure that all doors meet the requirement. Director of Maintenance and maintenance staff were educated by the Administrator on maintaining corridor doors to meet the requirement of smoke tight integrity and latch properly. The Maintenance Director/Designee will conduct one weekly audit of corridor doors to check function and integrity for four weeks. The audits will continue monthly thereafter. Results of audits will be reviewed at the Quarterly Quality Assurance and Improvement Committee Meeting over the duration of the audit process. Based on the results of the audits, a decision will be made regarding the need for continued submission and reporting.
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.
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.
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.
Corridor Doors Failed to Latch in Smoke Compartment
Penalty
Summary
Surveyors observed that two corridor doors, specifically those to Resident Room 217 and Resident Room 223, were not functioning as required. During an inspection, it was found that these doors were getting stuck in their frames, which prevented them from fully latching. This issue was directly observed between 10:56 am and 10:57 am on June 30, 2025. At the exit conference, both the Administrator and the Director of Maintenance confirmed that the doors failed to positively latch into their frames. The deficiency was limited to these two doors within one of six smoke compartments in the facility. No additional information about the residents in these rooms or their medical conditions was provided in the report.
Plan Of Correction
Maintenance has repaired the doors to rooms 217 and 223 to ensure that they latch appropriately. NHA to re-educate facility Maintenance Director on proper latching of corridor doors. A full house audit completed by maintenance to ensure that corridor doors were not getting stuck in their corresponding frames to prevent them from fully latching. Maintenance will conduct weekly audits x 4 weeks and monthly audits x 2 months to ensure doors latch appropriately. Audits to be submitted to QAPI for review and recommendations.
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