Failure to Maintain Exit Door Latching in Therapy Gym
Penalty
Summary
The facility failed to maintain exit doors in accordance with NFPA 101 (2012 Edition) during a facility tour conducted on March 12, 2025, between 9:00 a.m. and 3:00 p.m. An exit door in the therapy gym was observed to be not latching properly. This observation was confirmed through an interview with facility maintenance staff who were present during the tour. The deficiency is cited under NFPA 101 (2012 Edition) sections 19.2.2.2.1, 7.2.1, 7.2.1.5.10, and 4.6.
Plan Of Correction
On 3/12/25 the Maintenance Director/Maintenance Assistance evaluated the Exit Door in the therapy gym and made adjustments to the door so it could latch properly. ATTACHMENT #55 See corresponding email sent to area office dated 4/4/25 with attachments. On 3/12/25 the Maintenance Director inspected the other Exit Doors to ensure that the exit doors close and latch properly. During this inspection, there were no other exit doors that did not close and latch properly. ATTACHMENT #56 See corresponding email sent to area office dated 4/4/25 with attachments. On 3/12/25, the Administrator provided an inservice for the Maintenance and Therapy staff on the importance for exit doors to close and latch properly. The inservice included notifying the administrator/designee of any exit doors that do not close and latch properly and a plan to correct as indicated. ATTACHMENT #57 See corresponding email sent to area office dated 4/4/25 with attachments. The facility Maintenance Director/designee will audit facility exit doors weekly to help monitor and maintain proper latching for the facility exit doors. The monthly audit of exit doors will be recorded on a log. ATTACHMENT #58 See corresponding email sent to area office dated 4/4/25 with attachments. The Maintenance Director/designee will provide the monthly QAPI Committee a summary report on the findings from the audits of the facility exit doors for three (3) months. The QAPI committee will evaluate the outcome of the audits and if necessary amend the improvement plan and continue to monitor until sustained improvement has been determined by the committee. ATTACHMENT #59 See corresponding email sent to area office dated 4/4/25 with attachments.