Failure to Maintain Self-Closing Doors
Penalty
Summary
The facility failed to maintain doors with self-closing devices, as observed during a survey on January 22, 2025. Seven out of over ten doors were found to have deficiencies. Specifically, the laundry wet/dry room door did not positively latch in the frame, and the laundry wet room door was propped open. The laundry soiled utility room door failed to close and was dragging on the floor. Additionally, the kitchen door to the exterior and the kitchen dishwashing door both failed to close and latch in the frame. Furthermore, the Unit 1 fire door near resident room #127 and the Unit 2 corridor fire door also failed to latch in the frame. These deficiencies were confirmed in an interview with the maintenance supervisor.
Plan Of Correction
A. Laundry wet/dry room failed to latch: Maintenance replaced door handle to properly latch in laundry wet/dry room. Maintenance did audit of all self-closing device doors to ensure proper door latch function. NHA/designee to educate maintenance department by 21MAR2025 on the importance of ensuring door handles are operating properly. To prevent this from recurring, Maintenance will perform weekly x 4 audits on door latch function. Negative findings will be addressed. Ad Hoc education will be provided. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. B. Laundry wet room door propped open: Maintenance immediately removed the cart from the open laundry/wet room door. Maintenance did a whole house audit making sure no doors being propped open. Maintenance/designee to educate staff by 21MAR2025 on importance of not using items to hold doors open and having doors remain securely closed. To prevent this from recurring, Maintenance will perform weekly x 4 audits to ensure doors are not being propped open. Negative findings will be addressed. Ad Hoc education will be provided. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. C. Laundry soiled utility room failed to close/dragging: Maintenance adjusted laundry soiled utility room door to not drag on the floor and ensured properly closing. Maintenance completed an audit on all doors to ensure laundry soiled doors are closing properly. NHA/designee to educate maintenance staff by 21MAR2025 on importance of proper closure of all doors. To prevent this from recurring, Maintenance will perform weekly audits to ensure all doors are closing properly. Negative findings will be addressed. Ad Hoc education will be provided. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. D. Kitchen door to exterior failed to close and latch: Maintenance installed a magna lock with keypad to secure exterior kitchen door. Maintenance completed audit on all doors to ensure exterior kitchen door closed and latched properly. NHA/designee to educate maintenance staff by 21MAR2025 on importance of proper closure and latch of all exit doors. To prevent this from recurring, Maintenance will perform weekly audits to ensure proper closure and latching of doors. Negative findings will be addressed. Ad Hoc education will be provided. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. E. Kitchen dishwashing door failed to close and latch in frame: Maintenance adjusted kitchen dishwashing room door to close and latch properly. Maintenance completed audit on all doors to ensure closing and latch properly. Maintenance/designee will educate kitchen staff by 21MAR2025 on importance of ensuring proper closure and latching of all doors. To prevent this from recurring, Maintenance will perform weekly x4 audits to ensure entry and exit doors are closing and latching. Negative findings will be addressed. Ad Hoc education will be provided. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. F. Unit 1 Fire Door near #127 failed to latch in frame: Maintenance adjusted Unit 1 fire door to ensure door closed and latched properly. Maintenance completed audit on all fire doors to ensure closing and latching properly. NHA/Designee to educate maintenance staff by 21MAR2025 on importance of doors closing properly. Maintenance will do weekly x4 audit on all fire doors to ensure closing and latching properly. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. G. Unit 2 Fire Door failed to latch in frame: Maintenance adjusted Unit 2 fire door to ensure closed and latched properly. Maintenance completed audit on all fire corridor doors to ensure closing and latching properly. NHA/Designee to educate maintenance staff by 21MAR2025 on importance of doors closing properly. Maintenance will do weekly x 4 audits on all unit entry and exit fire doors to ensure closing and latching properly. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.