Non-compliance with Self-Closing Door Requirements
Penalty
Summary
The facility failed to maintain compliance with NFPA 101 standards regarding doors with self-closing devices. During an observation on March 19, 2025, at 10:48 a.m., it was noted that the door to the Dietary Dry storage area was being held open by an unapproved means, specifically a rubber wedge. This deficiency affected one of the eight smoke compartments within the facility. The issue was confirmed during an exit interview with the Facility Administrator and Facility Maintenance on the same day at 11:45 a.m.
Plan Of Correction
The Maintenance Director promptly took out the rubber wedge and closed the door to the dry food storage room. The facility Administrator educated both the Maintenance Director and the Food Service Director that, in accordance with life safety regulations, this door must never be propped open. To ensure compliance, the Maintenance Director will conduct weekly audits for a duration of four weeks, followed by monthly audits for three months, to verify that the dry food storage room door remains closed. The findings from these audits will be presented at the monthly Quality Assurance meeting for evaluation.