Hazardous Area Door Lacked Required Self-Closing Mechanism
Penalty
Summary
Surveyors observed that the facility failed to maintain proper hazardous area enclosures as required by NFPA 101. Specifically, during a tour of the facility, the egress door to the Dry Storage Area in the kitchen, which measured approximately 255 square feet and contained eight metal racks filled with dry food supplies, was found to be missing a self-closing mechanism. The absence of this mechanism was directly observed, and the staff member present confirmed that she was unaware the door required a self-closing device. This deficiency affected the kitchen and one of four smoke compartments in the facility. The report does not mention any specific residents or their medical conditions in relation to this deficiency. The finding was based solely on the physical observation of the hazardous area and staff interview at the time of the survey.
Plan Of Correction
Preparation and execution of this plan of correction does not constitute admission or agreement by this provider of the truth of the facts alleged or conclusions set forth in the Statement of Deficiencies. The plan of correction is prepared and executed solely because it is required by the provisions of federal and state law. I. Corrective Action The facility will ensure to maintain the hazardous area enclosures. On 04/02/2025, Maintenance Director installed a self-closing mechanism on the egress door to the Dry Storage Area in the kitchen (Attachment 2). II. Identify Other Residents at Risk Maintenance Director checked the Kitchen for all doors requiring self-closing mechanism. No other door was identified with the same deficiency. No residents were affected. III. Systematic Changes On 04/03/2025, in-service conducted by Administrator with kitchen staff about importance of self-closing mechanism on the door of Dry Storage Area (Attachment 3). Kitchen staff will perform daily check to ensure the door to the Dry Storage Area automatically closes. IV. Monitoring Process Maintenance Director will perform a monthly audit of all doors with self-closing mechanisms. Findings will be reported to Administrator in the daily operations meeting. Administrator will report any findings and trends monthly to the QA Committee for 3 months or until V. Completion Date 04/14/2025