Deficiencies in Hazardous Area Door Maintenance
Penalty
Summary
The facility was found to have deficiencies in maintaining the integrity of hazardous area doors, as observed during a survey on March 13, 2025. Specifically, the doors in four out of eight smoke zones exceeded the allowed gap margins. The affected areas included the Kitchen Scullery door, Main Kitchen door, Elevator Machinery Room door, and multiple Soiled Utility Room doors on both the 1st and 2nd floors. The gaps in these doors ranged from exceeding 1/8 inch to 3/16 inch, which is beyond the permissible limits for maintaining fire safety standards. Additionally, the Kitchen Scullery door on the 1st floor was observed to fail in self-closing, which is a requirement for hazardous area doors to ensure containment in case of a fire. These observations were confirmed during an exit conference with the Administrator and Maintenance Director, indicating a lapse in the facility's adherence to fire safety protocols as outlined in NFPA 101 standards.
Plan Of Correction
The 1st floor, Kitchen, Scullery door, top, exceeded 3/16 inch will be adjusted or repaired using approved hardware so gap does not exceed 3/16 inch. The 1st floor, Main Kitchen door, top and latch side, exceeded 3/16 inch will be adjusted or repaired using approved hardware so gap does not exceed 3/16 of an inch. The 1st floor, Elevator Machinery Room door, top and latch side, exceeded 1/8 inch will be adjusted or repaired using approved hardware so that the gap does not exceed 1/8 inch. The 1st floor, C Hall Soiled Utility Room door #1, top, exceeded 1/8 inch will be adjusted or repaired using approved hardware so that the gap does not exceed 1/8 inch. The 1st floor, C Hall Soiled Utility Room door #2, top and latch side, exceeded 1/8 inch will be adjusted or repaired using approved hardware so that the gaps do not exceed 1/8 inch. The 2nd floor, Soiled Utility Room door, by Infectious Control Room, top and latch side, exceeded 1/8 inch will be adjusted or repaired using approved hardware so that gaps do not exceed 1/8 inch. The kitchen scullery door will be repaired to make self-closing. Other doors to hazardous areas throughout the facility will be checked for proper gaps and adjusted or repaired using approved hardware as necessary. The Maintenance Director was re-educated on the need to maintain doors so that gaps are within acceptable range. The NHA or designee will audit door to hazardous areas for proper gaps monthly. A Time Limited Waiver is being requested until July 31, 2025 due to some doors may have to be replaced and the availability of the doors may take up to six months to obtain.