Failure to Maintain Self-Closing Doors in Hazardous Areas
Penalty
Summary
The facility failed to maintain self-closing doors at hazardous locations, affecting one of three levels in the facility. During an observation on April 15, 2025, several deficiencies were noted: at 12:40 p.m., the door at the Food Services office was binding in the frame, preventing it from latching; at 12:45 p.m., the door closure at the Dry Storage was broken, preventing the door from closing; and at 2:10 p.m., the hardware on the 2nd floor D wing's storage closet was broken, preventing the door from latching. These deficiencies were confirmed during an exit interview with the Administrator, Maintenance Director, and Regional VP of Operations.
Plan Of Correction
1) A. Food Service Office Door and frame was replaced and latches as required. B. Dry Storage door closure was repaired and closes properly. C. 2nd Fl. D Wing storage closet, hardware was replaced and the door latches as required. 2) The Maintenance Director and/or designee inspected all self-closing doors in hazardous locations to ensure that the doors latch and close as required. 3) To prevent the potential for reoccurrence, the Administrator and/or designee educated the Maintenance Director and/or designee on the importance of self-closing doors in hazardous locations close and latch as required. 4) To monitor and maintain ongoing compliance, the Administrator and/or designee will audit all self-closing doors in hazardous locations monthly for 3 months to ensure compliance. If an issue is identified, the door/s will be fixed immediately and the Maintenance Director and/or designee will be reeducated. Findings will be reported to facility QAPI for continued review and recommendations.