Failure to Maintain Self-Closing Door Latch
Penalty
Summary
The facility failed to maintain doors with self-closing devices as required by NFPA 101 standards. During an observation, it was noted that one of the two leaves of the self-closing doors in the corridor from the 300 wing to the dining room area did not positively latch in the frame. This deficiency was confirmed through an interview with the maintenance supervisor, who acknowledged the issue with the self-closing door.
Plan Of Correction
This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because Communities at Indian Haven agrees with the allegations and citations listed on the statement of deficiencies. Communities at Indian Haven maintains that the alleged deficiencies do not, individually, and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Communities at Indian Haven's written credible allegation of compliance. By submitting this plan of correction, Communities at Indian Haven does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Communities at Indian Haven reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action. K0023 1. Door on 300 wing has been adjusted. Both leaves positively latch. 2. House audit shows other doors positively latch as required. 3. Weekly checks of self closing doors will be documented by maintenance supervisor or designee ongoing. 4. A monthly random door audit will be conducted by administrator or designee for 3 months. Reviews submitted to QAPI's Safety Committee for review. Administrator to monitor for compliance.