Deficiencies in Hazardous Area Door Maintenance
Penalty
Summary
The facility was found to have deficiencies in maintaining hazardous area doors within the allowed gap margins and in good repair. During an observation on December 16, 2024, it was noted that doors in three of four smoke zones had gaps greater than one-eighth of an inch. Specifically, the laundry's soiled-side and clean-side doors, as well as storage room doors across from the Nurses' Station and by Resident Room 418, all exhibited gaps exceeding the permissible size. This was confirmed through an interview with the Director of Maintenance. Additionally, the hazardous area doors were found to be damaged and repaired using unauthorized or unidentified substances. The laundry's soiled-side door was damaged on the surface and edge and filled with an unauthorized filler, while the clean-side door was also damaged on the surface and edge. These findings were again confirmed by the Director of Maintenance during the interview.
Plan Of Correction
1. The facility will request a TLW to correct K321, so that the facility can have adequate time to order and replace laundry soiled side door, laundry clean side door. The facility will also request TLW to have adequate time to repair gaps in the laundry soiled side door, laundry clean side door, Central Supply door, and Storage Room door by room 418. TKW request until 6/19/2025. 2. The Maintenance Supervisor will receive re-education by the Administrator on the allowed gap margins for interior doors. 3. The facility will complete an initial audit of all facility doors then audit 5 facility doors per week for 4 weeks to ensure that the door gap margins do not exceed the allowed gap margins, then quarterly for one year. 4. Audits will be reviewed at the next QAPI meeting.