Non-Latching Corridor Doors Compromising Smoke Compartment Integrity
Summary
Surveyors observed that the facility failed to maintain corridor doors in accordance with regulatory requirements. Specifically, during a facility tour, two corridor doors—one to the Shower Room by Room 6 and another to the Salon by Room 13—were found to have self-closing mechanisms but did not latch when tested for closure. Each door was tested approximately three times and failed to latch on each attempt. Staff interviews indicated that the Shower Room door may have required lubrication, while the Salon door's failure to latch was attributed to air pressure in the room. This deficiency affected 34 of 92 residents and two of six smoke compartments within the facility. The non-latching doors could allow the passage of smoke between compartments, as the doors did not resist the passage of smoke as required. No specific resident medical histories or conditions at the time of the deficiency were mentioned in the report.
Plan Of Correction
K 363 - Corridor Doors How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: • Maintenance staff lubricated and adjusted the self-closing mechanisms on the Shower Room door by Room 6 and the Salon door by Room 13 to ensure proper latching. • The EVS Director replaced both door handles on 4/10/25 to ensure proper latching. • Both doors were tested three times and successfully latched upon closure. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: • No additional residents have the potential to be affected. This latching concern only affects the two smoke compartments and cannot affect the other smoke compartments. • On 4/10/25 a facility-wide inspection was conducted to identify any other door latching issues. No other issues were found. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: • On 4/10/25 a facility-wide inspection was conducted to identify any other door latching issues. No other issues were found. • The maintenance team has implemented a monthly inspection schedule to ensure all corridor doors latch properly and self-closing mechanisms function as required. • The EVS Director was trained by the Administrator on the importance of proper door maintenance, including lubrication, alignment, and troubleshooting air pressure issues that may affect door closure. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: • The maintenance team has implemented a monthly inspection schedule to ensure all corridor doors latch properly and self-closing mechanisms function as required. • Results will be reviewed in the QAPI meetings for ongoing compliance oversight. Date of Compliance 4/18/25
Penalty
Surveyors found that two corridor doors would not latch despite multiple attempts, and a staff member was unaware of the regulatory requirements. This deficiency had the potential to affect 17 residents, as the doors did not meet NFPA 101 standards for smoke resistance and positive latching.
Surveyors found a corridor door held open by an unapproved chain and magnet, which interfered with the door's latching mechanism and did not meet NFPA requirements for smoke resistance and positive latching, potentially affecting 13 residents.
Failure of Corridor Doors to Latch as Required by NFPA 101
Penalty
Summary
During a facility tour, surveyors observed that the corridor doors to residents' rooms A-9 and B-12 would not latch despite three attempts to secure them. These doors are required by NFPA 101-2012 standards to resist the passage of smoke and be equipped with positive latching hardware. The failure of these doors to latch was confirmed through direct observation and staff interviews. The staff member interviewed at the time, identified as MD#1, acknowledged the issue and stated he was unaware of the specific requirements for corridor doors. The deficiency was noted to have the potential to affect 17 out of 46 residents, as the non-latching doors did not meet the regulatory standards for corridor openings, which are intended to prevent the spread of smoke and maintain fire safety within the facility.
Plan Of Correction
K363 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 07/30/25 as the facility's allegation of compliance date. The facility failed to ensure that resident room doors A9 and B12 would not latch. Step 1: Director of Maintenance fixed resident room doors A9 and B12 on 6/6/25. Step 2: Maintenance Director completed house audit to ensure that all resident doors latched properly when closed on 6/6/25, with no negative findings. Step 3: LNHA educated Director of Maintenance on corridor doors and safety to ensure proper functioning when closed on 7/15/25. Step 4: NHA/designee will audit corridor room doors to ensure ongoing compliance weekly x4 then monthly x2. The results of the audits will be submitted to the QAPI Committee for further review and recommendations. --- K0372 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 07/30/25 as the facility's allegation of compliance date. The facility failed to ensure smoke barrier in Rm #B9 would resist passage of smoke. Step 1: Penetrations in Rm#B9 were sealed to resist passage of smoke to prevent passage of smoke creating a sealed/contained smoke compartment on 6/6/25. Step 2: All resident rooms audited for penetrations by 7/15/25. Step 3: Maintenance Director educated by LNHA on the smoke barrier function of the ceiling and maintaining the integrity of the ceiling on 7/15/25. Step 4: To monitor and maintain compliance, LNHA/designee will audit smoke barriers for compliance weekly for X4, then monthly X2. Results of the audits will be forwarded to the facility QAPI committee for further review and recommendation.
Noncompliant Corridor Door Hold-Open Device
Penalty
Summary
The facility failed to ensure that all corridor doors were able to resist the passage of smoke and were provided with a suitable means for keeping the doors closed, as required by NFPA 101-2012 and NFPA 80-2010 standards. During a facility tour, surveyors observed a 20-minute fire-rated double-corridor door being held open by an unapproved chain with a magnet attached. This setup was not compliant with regulations, as the magnet on the chain could interfere with the door's latching mechanism and was not an approved device for holding the door open. The magnet, when the door closed, would swing on its chain and potentially interfere with the door's ability to latch properly. This deficiency was confirmed through interviews with the Regional Maintenance Director and the Maintenance Director, who acknowledged the findings at the time of observation. The improper use of the chain and magnet did not meet the requirement for corridor doors to have positive latching hardware and to resist the passage of smoke. The report specifies that this deficiency had the potential to affect 13 out of 39 residents in the facility. No additional details about the specific residents or their medical conditions were provided in the report. The deficiency was limited to the improper securing of a fire-rated corridor door, which did not comply with the required fire and smoke protection standards.
Plan Of Correction
Tag: K 0363 Chain and magnet on double corridor door modified to keep from impeding closure on 6/20/25. No other fire rated or smoke barrier doors found to be impeded from closing appropriately. Administrator educated maintenance director on NFPA 101 corridor doors on 6/16/25. Maintenance director or designee will audit all corridor doors weekly x 4 weeks. Audit results will be submitted to the QAPI committee for review and recommendations.
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