Improper Latching of Soiled Utility Room Door
Summary
The facility failed to ensure that a hazardous area door, specifically the soiled utility room door on the fourth floor, latched completely in its frame. This deficiency was observed during a life safety survey conducted on December 3rd and 4th, 2024, between 09:30 am and 02:30 pm. On December 3rd, at approximately 10:43 am, the door to room 425 was tested and found not to latch properly. During an interview, the maintenance director acknowledged the issue and indicated it would be corrected immediately.
Plan Of Correction
Plan of Correction: Approved December 19, 2024 Immediate Corrective Action: The Maintenance Director and facility team on 12.03.2024 adjusted the hinges on the door for the Soiled Utility Room (RM-425) that failed to latch in its frame. The facility team on 12.04.2024 successfully completed and tested the requested work order from the Senior Administrator to ensure the Hazardous Area – (RM-425) designated as the Soiled Utility Room was equipped with a door that properly latched. Identification of Others Potentially Affected: The facility respectfully submits all residents were potentially affected by this practice. System Changes to Prevent Recurrence: The Compliance Officer has updated the daily compliance facilities testing tracker to identify hazardous areas that are artificially propped open or inoperable to latch in its frame. The facility supervisor will observe and test the latches within Hazardous areas during the daily (M-F) maintenance rounds. Any discrepancies will be logged and immediate work order(s) submitted for approval by the executive team. Quality Assurance Monitoring: The Maintenance Director will conduct weekly review/reconciliation on the test logs, monthly test reports and vendor reports to ensure complete compliance with the required Life Safety Code testing lists. Any maintenance/testing that is required will be documented and subjected to quarterly internal audit by the quality assurance unit. Responsible Party: Maintenance Director
Penalty
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