Failure to Maintain Hazardous Area Door in Basement
Penalty
Summary
A hazardous area in the basement of the facility was not maintained properly, as observed during a Life Safety Code survey. The door to the clean linen storage room, which is a hazardous area, failed to self-close and latch into its door frame. This room was larger than 50 square feet and contained multiple clean linen carts and shelving units filled with clean linen. During the observation, the Maintenance Supervisor acknowledged that the door's self-closing device had been replaced multiple times and that the top hinge was broken. The Maintenance Supervisor also mentioned that both the door and its frame required replacement. Additionally, the facility lacked documentation for audits of hazardous area doors, as stated by the Maintenance Supervisor during a subsequent interview.
Plan Of Correction
Plan of Correction: Approved February 26, 2025 The door identified during the survey as not self-closing and latching into its door frame has been repaired to and is currently working properly and per regulation. The facility is in the process of obtaining quotes to ultimately replace the door, which will occur post survey compliance date. An audit and review of all facility self-closing doors has been completed to assure that they are also closing and latching fully into their frames. Any other doors found to be malfunctioning will be repaired to assure they self-close and latch fully into the door frame. A review of the facility's policy related to the routine inspection of self-closing and latching doors has been completed to assure it contains language specifying the frequency and scope of such checks. Door audits will be documented and maintained in a binder within the maintenance department. All maintenance staff will receive education and in-service training on this updated policy and procedure. An audit of all self-closing and latching doors will be completed weekly for six weeks to assure all doors are operating per regulation. These audit results will be placed on the agenda of the Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Director of Maintenance will be responsible for ongoing compliance with these corrective measures.