Improper Use of Device to Hold Open Corridor Door
Penalty
Summary
During a Life Safety Code recertification survey, it was observed that a corridor door leading to the dining room was improperly held open using a hand sanitizer portable stand. This action was not in compliance with the NFPA 101: Life Safety Code, which requires that doors not be held open by devices other than those that release when the door is pushed or pulled. The Director of Environmental Services acknowledged the finding at the time of observation. The deficiency was noted as the facility failed to ensure that corridor doors were provided with suitable means to keep the door open in accordance with the specified safety code.
Plan Of Correction
Plan of Correction: Approved January 28, 2025 I. Plan of Correction for Affected Residents: The facility respectively states that no Residents were affected by this deficient practice. 2) On 12/27/2024, The Director of Maintenance removed the portable hand sanitizer stand that was preventing the (NAME) dining room door from closing. 3) On 01/14/2025, The Director of Maintenance contacted the Fire Alarm contractor to provide a proposal to install magnetic hold open devices that are connected to the fire alarm system that will release when the fire alarm is activated. That proposal was received on 01/17/2025 and has been approved. The magnetic hold open devices will be installed by 02/28/2025. II. Plan of Correction to identify other Residents Potentially Affected: All residents have the potential to be affected by this deficient practice. On 01/14/2025, The Director of Maintenance inspected all corridors doors and no other areas of noncompliance were noted. III. Plan of Correction for Systems Changes and Measures to Prevent Recurrence: A) On 01/14/2025, The Director of Maintenance in conjunction with maintenance staff reviewed the requirements for K363 to understand and implement the corrective actions. B) Environment rounds will be done for all corridor doors to ensure that they resist the passage of smoke. C) Findings of rounds will be recorded in an audit tool located in the maintenance log book. IV. Plan of Correction for Monitoring Corrective Actions: A) The Director of Maintenance/designee created an audit tool and will conduct quarterly audits of the corridor doors for 12 months to ensure compliance with 2012 NFPA 101: 7.10.2, 7.10.2.1, 10 NYCRR: 711.2 (a). B) The Director of Maintenance/designee will report findings of the audit to Administrator. C) Any negative findings from these audits will be immediately addressed by the Director of Maintenance and Administrator. The findings of these audits will be discussed at the quarterly QAPI meetings to discuss any unfavorable trends and patterns that may prevent achieving 100% compliance. I. Responsible Discipline: The Director of Maintenance is responsible to ensure that all components of the plan of correction have been implemented and that compliance has been achieved. Date of Completion: 02/28/2025