Corridor Doors Not Smoke-Resistant
Summary
The facility failed to ensure that all corridor doors were maintained to resist the passage of smoke, as required by safety regulations. During a life safety survey conducted on February 10, 2025, it was observed that transfer grilles were present on corridor doors across multiple floors, specifically on floors 1 through 4. These grilles were found on the doors to janitor's closets near rooms 4C25 and 4D08 on the 4th floor, near rooms 3A08, 3D08, and 3B25 on the 3rd floor, near rooms C25 and D08 on the 2nd floor, and on the utility room door near the activities room on the 1st floor. The presence of these grilles violates the requirement that corridor doors must be constructed to resist the passage of smoke, as outlined in the 2012 NFPA 101 and 2011 NFPA 25 standards, as well as 10 NYCRR 711.2 (a).
Plan Of Correction
Plan of Correction: Approved February 24, 2025 I. Immediate Corrective Action The transfer grilles which were found on corridor doors in the following locations were closed off with metal plates: 1) On the doors to the janitor's closets near rooms 4C25 and 4 DO8 on the 4th floor. 2) On the 3rd floor janitor's closets near rooms 3A08, 3D08 and 3B25. 3) On the 2nd floor near rooms 2C25 and 2D08. 4) On the 1st floor on the utility room near the activities room. II. Identification of Other Residents a. An audit has been conducted of all corridor doors throughout the facility to make sure all doors close and latch as required with proper sealing to prevent the transfer of smoke. b. No additional doors were found noncompliant. c. No residents' additional residents were found to be affected upon completion of this review. III. Systemic Changes 1. The facility has reviewed the Preventive Maintenance Plan and door inspection policy and revised the same to include directives for ventilation grilles, as well as inspection observations. 2. All Maintenance staff will be educated by the maintenance director on the Preventive Maintenance Plan and requirement for appropriate Door operation. 3. The Lesson Plan will concentrate on the following: > Overview of requirements for K363 > Preventive Maintenance plan for performing observational inspections of the doors > Responsibility for providing appropriate door closures. 4. A copy of the Lesson Plan and attendance will be filed for reference and validation. a. The facility reviewed and revised its policy regarding corridor doors. b. All maintenance staff were in service on the updated corridor door policies. IV. QA monitoring a. An audit tool was created to monitor the facility’s corridor doors. b. Monitoring of the facility’s doors shall be performed monthly for the first 3 months and then quarterly thereafter for 9 months. c. Any negative findings from inspections shall be reported to the administrator for further evaluation and will be addressed. d. All reports shall be brought to the Quality Assurance meeting to review with the team to ensure that repairs are being performed in a timely manner for 12 months. V. Title Responsible Director of maintenance
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.
Surveyors found that two resident rooms had wooden door wedges holding corridor doors open, preventing them from closing as required for fire safety. Facility staff confirmed that the wedges impeded proper door closure.
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 Blocked Open with Wedges
Penalty
Summary
Surveyors observed that the facility failed to maintain corridor doors in accordance with fire safety regulations on two of four levels. Specifically, during an inspection, it was found that a resident room on the fourth floor and another on the second floor each had a wooden door wedge holding the door open. These wedges prevented the doors from closing as required to resist the passage of smoke and maintain corridor safety. The Maintenance Supervisor and Director of Safety/Security confirmed during an exit interview that the use of door wedges inhibited the proper closing of the doors. The deficiency was identified through direct observation and staff confirmation, with no mention of any specific resident conditions or medical histories related to the incident.
Plan Of Correction
Door stops have been removed from doors. All other rooms checked for door stops and none noted. Staff will be educated to not use door stops. Residents and families will be educated upon admission that door stops cannot be used, and current residents will be educated regarding door stops at the next resident council meeting. The resident welcome book has been updated to include education regarding door stops and will be distributed to all residents upon admission and to all current residents.
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