Failure to Maintain Self-Closing Doors in Hazardous Storage Areas
Summary
Surveyors observed that the facility failed to ensure proper protection of hazardous areas as required by Life Safety Code (LSC) 19.3.2.1. Specifically, on two separate occasions, it was found that the doors to the Therapy storage closet and the 100 back hall storage closet (used for emergency food and water storage) did not self-close to a positive latch. These deficiencies were identified during direct observation and confirmed through interviews with the Maintenance Technician present at the time. The report notes that these failures could potentially affect 20 occupants in the event of a fire not being contained to the hazardous area. No information about corrective actions or follow-up measures is included in the report, and there are no details provided about specific residents or their medical conditions at the time of the deficiency.
Penalty
A faulty door closure was observed on the South Nurses' Station and Food Storage Room, resulting in the door failing to automatically close and latch as required for hazardous area enclosures. This deficiency was confirmed by the DON and Director of Maintenance.
Surveyors found that the door to a third-floor trash room, classified as a hazardous area, did not self-close or positively latch as required. This issue was confirmed by facility staff during the inspection.
A deficiency was found when the A Hall Resident Care Supply room door did not self-close to a positive latch as required by LSC 8.7.1.3, leaving a hazardous area inadequately protected according to fire safety standards.
Surveyors identified that hazardous area doors, including the Sprinkler Tank Room and 1st floor Dietary Storage Room, were not maintained within required gap margins and were held open with unauthorized devices, as confirmed by the Director of Facilities.
A door to the Service Hall Food Storage Room was found dragging on the floor and failed to self-close and latch, compromising the smoke resistance required for hazardous area enclosures. This issue was confirmed by facility leadership during the survey.
During a survey, it was observed that the soiled utility room door in the 600 hall did not latch when closed, failing to meet requirements for hazardous area fire barrier protection. This deficiency was confirmed with the maintenance director and could allow smoke or fire to escape into the emergency egress corridor.
Deficient Fire Barrier Door Closure in Hazardous Area
Penalty
Summary
The facility failed to maintain the required fire safety standards for hazardous area enclosures in one of five smoke compartments. During an observation, it was found that the door to the South Nurses' Station and Food Storage Room did not automatically close and latch within the door frame due to a faulty door closure. This deficiency was confirmed during an interview with the Director of Nursing and the Director of Maintenance, who acknowledged that the door failed to function as required.
Plan Of Correction
1. The South Nurses Station and Food Storage Room door closure was adjusted to ensure positive latch. 2. A facility-wide audit was completed to ensure positive latch of required doors. 3. The Environmental Services Director was re-educated on the requirements of K0321. Monthly door latch audits will occur. 4. The NHA or designee will complete a random audit of facility doors weekly x 4 weeks then monthly x 2 months to ensure positive latch. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring. K 0321
Deficient Self-Closing and Latching Door in Hazardous Area
Penalty
Summary
Surveyors observed that the facility failed to ensure the door to the trash room on the third floor was self-closing and positively latching, as required for hazardous area enclosures. During the inspection, it was noted that the rated door did not close automatically or latch securely when tested. This deficiency was confirmed during an exit interview with the Maintenance Supervisor and the Director of Safety/Security, who acknowledged that the door did not function as required.
Plan Of Correction
Door has been fixed and is latching appropriately. Doors will be monitored during environmental rounds by maintenance staff.
Hazardous Area Door Failed to Self-Close and Latch
Penalty
Summary
A deficiency was identified when the A Hall Resident Care Supply room door was observed not to self-close to a positive latch as required by Life Safety Code (LSC) 8.7.1.3. This observation was made during a facility inspection and confirmed in an interview with a maintenance staff member. The lack of a self-closing, positively latching door in this hazardous area means the area was not properly protected as required for spaces containing combustible or hazardous materials, as outlined in LSC 19.3.2.1. The deficiency was specifically noted in relation to the protection of hazardous areas, which is necessary to prevent the spread of fire and smoke within the facility.
Plan Of Correction
Element #1: A Hall Resident Care Supply room door self-closer has been adjusted. The A Hall Resident Care Supply room door was checked to ensure the door self-closed to a positive latch. Element #2: This deficient practice has the potential to affect 15 occupants of the facility in the event of a fire not being contained to the hazardous area. Hazardous area doors in the facility have been checked and verified that they self-close to a positive latch. Doors that did not self-close to a positive latch were fixed at the time of the audit. Element #3: Nursing Home Administrator/designee has completed re-education with the Environmental Service Director on the Fire and Smoke Doors policy by the completion date. Element #4: Environmental Services Director/designee will complete audits on hazardous area doors to ensure they self-close to a positive latch. Audits will be completed weekly for four weeks and then monthly thereafter until substantial compliance is sustained. Results of the audits will be reported to facility QAPI committee for review and recommendations. This plan of correction will be monitored at the routine Quality Assurance (QAPI) meeting until such a time it is identified by the committee that sustained substantial compliance has been achieved. The Nursing Home Administrator is responsible for attaining and maintaining compliance.
Hazardous Area Door Deficiencies and Improper Hold-Open Devices
Penalty
Summary
The facility failed to maintain hazardous area doors in accordance with required safety standards in two of ten smoke zones. Specifically, during an observation, the Sprinkler Tank Room door (1A29D) was found to have gaps greater than 3/16 inch, which exceeds the allowed gap margins for such doors. This was confirmed by the Director of Facilities at the time of observation. Additionally, the 1st floor Dietary Storage Room rated doors (1B20) were observed being held open with manual hold-open drop downs, which are unauthorized devices. The Director of Facilities confirmed that these doors were being held open in this manner. These findings indicate that the facility did not ensure hazardous area doors were properly maintained to meet fire safety requirements.
Plan Of Correction
1. A rated door system will be installed on door 1A29D to maintain proper gap margins to less than 3/16". A recurring work order will be created to inspect the door for proper gap margins quarterly for one year. Completed work order documentation will be presented to QAPI for evaluation. 2. Manual hold open devices will be removed from doors 1B20. A recurring work order will be created to inspect doors for proper operation and positive latching quarterly for one year. Completed work order documentation will be presented to QAPI for evaluation.
Failure of Hazardous Area Door to Self-Close and Latch
Penalty
Summary
Surveyors observed that the door to the Service Hall Food Storage Room did not self-close and latch within the door frame as required for hazardous area enclosures. The door was found dragging on the floor, which prevented it from closing and latching properly. This deficiency was confirmed during an interview with the Administrator and Maintenance Director, who acknowledged that the door failed to self-close and positively latch, thereby compromising the smoke resistance of the hazardous area enclosure in one of seven smoke compartments.
Plan Of Correction
1. The door to the Service Hall food storage room will be modified and/or replaced to allow self-closure and latching within the door frame, and repair the drag on the floor. A time-limited waiver will be requested if door replacement is required. 2. A time-limited waiver will be requested until 1/5/2026 for the door replacement in the Service Hall food storage room. Maintenance will complete monthly door checks to verify ongoing compliance with regulatory requirements, and report any negative findings to the QAPI Committee monthly. Date of compliance is 7/30/2025.
Deficient Fire Barrier Protection in Hazardous Area
Penalty
Summary
A deficiency was identified when, during an observation on June 24, 2025, the door to the soiled utility rated room in the 600 hall was found not to latch when closed. This door is required to be self-closing or automatic-closing and to latch in order to maintain the integrity of the fire barrier, as specified by regulatory requirements for hazardous area enclosures. The failure of the door to latch could allow smoke, heat, fire, or biohazard to escape the rated space and enter the emergency egress corridor. The findings were confirmed through an interview with the maintenance director at the time of observation. No specific information about the medical history or condition of the affected occupants was provided in the report.
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