Hazardous Area Doors Not Maintained
Penalty
Summary
During a Life Safety Code survey, it was observed that hazardous area doors in the facility were not maintained properly, affecting multiple units and areas. Specifically, doors in Unit 1/2 and Unit 5 on the First Floor, as well as several storage and utility rooms in the Basement and the Second Floor Administration area, failed to self-close and latch into their door frames. In some cases, the doors were obstructed by objects such as a five-gallon bucket or had their self-closing devices detached, preventing them from functioning correctly. These deficiencies were noted in areas storing soiled linen, trash, medical supplies, and other materials. The survey revealed that in several instances, the doors were intentionally obstructed or altered to facilitate easier access for staff, such as taping over latch plates or removing door closer arms. The Maintenance Director acknowledged these issues during interviews, indicating that staff might have removed door closer arms to ease the movement of supplies. Additionally, some doors were found to be hung up on the floor, preventing them from closing properly, and requests for necessary tools to fix these issues had not been approved by the facility's owner. The facility had documentation of inspections conducted on hazardous area doors, but the deficiencies observed during the survey suggest that these inspections were either inadequate or not acted upon. The report does not mention any immediate corrective actions taken by the facility to address these issues, nor does it indicate any potential consequences or risks directly stated in the report.
Plan Of Correction
Plan of Correction: Approved January 2, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. A 100% audit of all doors/latches and doorframes was conducted on 1/3/2025 to ensure proper functioning. The door to Unit 1/2 Soiled Utility Room (near Resident room [ROOM NUMBER]) latch on the inside the door was repaired by Maintenance Director. Unit 5 Soiled Utility Room (near Resident room [ROOM NUMBER]) was repaired by Maintenance Director. Folded paper towels that were taped over the latch plate preventing the door from latching were removed during survey 12/6/2024. Unit 5 apartment door was repaired by Maintenance Director. Basement - LaVerna was repaired by Maintenance Director. The arm of the self-closing device on the right leaf was re-attached to the door. Basement - A Wing Housekeeping Storage Room Door (A6) was repaired by Maintenance Director. Basement - A Wing Storage Room door (A2) was repaired by Maintenance Director. The door's self-closing device was re-attached to the door. Basement - B Wing Housekeeping Supply Storage Room Doors (B5) and (B7) was repaired by Maintenance Director. The arms on both door's self-closing devices were re-attached to the doors. Basement - C Wing Housekeeping Storage Room door (C12) was repaired by Maintenance Director. Basement - C Wing Boiler Room door (C10) was repaired by Maintenance Director. The floor of the C Wing Corridor was grounded down so the door no longer got hung-up on it. Basement - Activities Storage Room door (A1) was repaired by Maintenance Director. The floor of the basement's center corridor was grounded down so the door no longer got hung-up on it. 2nd Floor Administration area - kitchenette was repaired by Maintenance Director. The floor of the kitchenette was grounded down so that the door no longer got hung-up on it. 2. All residents are at risk for deficient practice of hazardous doors not closing and latching in the frame. 3. All hazardous doors were audited by Maintenance Director for deficient practice of doors not closing and latching in frame. Any deficient finding was immediately repaired. 4. Policy and Procedure for hazardous doors was reviewed by Administrator. No change was made to policy. 5. All staff were in-serviced by the Consultant regarding the regulation for properly functioning doors, notification to maintenance regarding improperly functioning doors, and deficient practice of obstructing doors. Administrator inserviced Maintenance Director/Tech on policy and procedure for Hazardous Doors. 6. Monthly Audits of door/latches and door frames will be conducted by the Director of Maintenance and reviewed by the Administrator at the monthly QAPI meeting. Any deficient findings will be corrected and brought to QAPI. Person Responsible: Maintenance Director