Failure to Maintain Self-Closing Doors
Penalty
Summary
The facility failed to maintain doors with self-closing devices on four of over twenty floors, as observed during a survey on January 14, 2025. Specific deficiencies included the kitchen door to the trash hall failing to latch in the frame, basement corridor doors near the laundry having disconnected self-closing devices and failing to close and latch, the laundry door between the wet and dry rooms failing to latch, and the corridor door to the therapy room having a disconnected self-closing device and failing to close and latch. These observations were confirmed through an interview with the maintenance supervisor.
Plan Of Correction
Maintenance staff have been educated on the need for proper operating functions of self-closing doors and how to identify the need for them. Self-closing doors have been ordered and will be placed on each door. This process will be audited in our Quality Assurance Performance Improvement Plan quarterly, with random auditing performed by the maintenance director to ensure self-closing doors are in operation and closing appropriately.