Hazardous Area Door Gap Deficiency
Penalty
Summary
The facility failed to maintain the hazardous area doors within the allowed gap margins in one of the four smoke zones. Specifically, during an observation on December 18, 2024, at 12:10 PM, it was noted that the Kitchen Storage Room door had a gap at the top that exceeded the minimum allowed margin by 3/16-inch. This deficiency was confirmed during an interview at the exit conference with the Administrator and Director of Maintenance on the same day at 1:15 PM.
Plan Of Correction
The facility to correct the kitchen door by utilizing a door adjustor to meet the gap requirement. An audit of all hazardous doors will be audited to ensure compliance. The facility will complete a random audit of the hazardous doors quarterly. Education provided to maintenance staff regarding hazardous door requirements. The findings from the audits will be reported to QAPI for 6 months.