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K0222
E

Improper Locking Device on Kitchen Refrigerator/Freezer Egress Door

Plainwell, Michigan Survey Completed on 05-06-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when a hasp with a padlock was observed mounted to the outside of the refrigerator/freezer door in the kitchen. This setup created the potential for someone to be locked inside the refrigerator/freezer, which is a violation of Life Safety Code (LSC) section 7.2.1.5.3. The presence of the padlock and hasp on the egress door did not comply with the requirements for approved exit access, as doors in a required means of egress should not require a tool or key for exit unless specific special locking arrangements are met. The observation was made during a facility inspection, and the findings were confirmed in an interview with the Maintenance Director at the time of the observation. The report does not mention any specific residents or staff being directly affected at the time, nor does it provide details about any medical history or conditions of individuals involved. The deficiency was limited to the physical environment and the improper installation of a locking device on an egress door in the kitchen area.

Plan Of Correction

K222 Egress Doors Element 1 No residents were harmed due to this deficient practice. All staff have the potential to be affected by this deficient practice. The hasp with a padlock mounted to the outside of the refrigerator/freezer door was removed in order to prevent accidental locking of someone inside. Element 2 The Maintenance Director audited other refrigerators and freezers in the facility to ensure that all opened and closed properly without the threat of accidentally locking someone inside. No concerns were identified. Element 3 Education was provided to the maintenance director on refrigerator and freezer doors that need to open and close properly per K222. Element 4 The Maintenance Director or Designee will audit the refrigerator/freezer doors one-time weekly times 4 weeks then monthly times three months to ensure that the doors are closing and locking properly. Any concerns will be addressed at the time they are discovered. Audit findings will be presented to and reviewed by the QAPI Committee monthly until such time that consistent substantial compliance has been achieved and maintained as determined by the committee. The Maintenance Director will be responsible for sustained compliance.

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