Deficiency in Self-Closing Doors for Hazardous Areas
Summary
During a life safety survey conducted on January 6, 2025, it was observed that the facility failed to ensure that all doors protecting hazardous areas were equipped with self-closing or automatic closing mechanisms. This deficiency was noted on the first floor of the building, specifically involving the door to a large dining room being used to store a shipment of furniture and the laundry room door in the exit passageway leading to the loading dock. The absence of self-closing doors in these areas was confirmed through observation and staff interviews, with the Director of Environmental Services acknowledging the need for installation of self-closers.
Plan Of Correction
Plan of Correction: Approved January 24, 2025 I. Immediate Corrective Action The maintenance department installed self-closing hinges to the dining area doors located on the first (1st) floor, compliant with 19.3.2.1.3 N.B. – The dining room housed a delivery of furniture that has been returned to the company. The maintenance department also installed self-closing hinges to the laundry room door, compliant with 19.3.2.1.3. II. Identification of Other Residents The Environmental Service Director inspected all doors to hazardous areas in the facility and found same to be compliant. Once the dining room doors and the laundry room door had self-closing hinges installed, the facility respectfully states that no other residents were affected by this practice. III. Systemic Changes The Environmental Service Director will provide In-service education to all maintenance staff related to the requirements of Hazardous area protection. Lesson Plan and Attendance will be filed for validation. The Environmental Service Director will develop an audit tool to track compliance. IV. QA Monitoring The Environmental Service Director shall utilize the audit tool to monitor that all hazardous area doors are compliant with 19.3.5.9. The Environmental Service Director/designee shall conduct the audits monthly for six (6) months, and quarterly thereafter. Any negative findings will be corrected immediately by the maintenance department and reported to the Administrator. All audit findings will be reported and reviewed quarterly at the QAPI committee meeting. Responsible Party: Director of Environmental Service
Penalty
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