Failure to Maintain Self-Closing Doors
Penalty
Summary
The facility failed to maintain two doors with self-closing devices, which affected one of six smoke compartments. During an observation on April 30, 2025, between 10:14 am and 10:21 am, it was noted that the doors did not positively latch into their frames. Specifically, the door at Nurse's Station 2 and the door of Resident Room 62, which is tied into the fire alarm system, were identified as not latching properly. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager at 11:00 am on the same day.
Plan Of Correction
The Nurse's Station 2 door and Resident Room 62 door assembly was adjusted to provide positive latching by facility maintenance department. The Maintenance Director/designee will conduct a facility wide audit to identify doors requiring adjustment to fully latch and coordinate repairs as identified. The Nursing home Administrator will provide re-education to the Maintenance Director on proper door latching requirement. The Maintenance Director will conduct audits on latching doors to verify compliance weekly x 4 weeks, then monthly x 2 months. The results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for compliance.