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K0363
D

Corridor Door Obstructions and Improper Hold-Open Device

Pomona, California Survey Completed on 05-05-2025

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

Surveyors observed that the facility failed to maintain corridor doors in compliance with NFPA 101 requirements in one of eight smoke compartments. Specifically, in Resident Room 139, a bed was positioned in such a way that it impeded the closure of the corridor door, preventing it from closing and positively latching as required. The maintenance staff member present had to move the bed to allow the door to close properly, acknowledging that the door closure pathway should remain clear. Additionally, in the Medical Records Office, the corridor door was found to be held open by a kick down stopper, which is not an approved automatic door release device. The maintenance staff member confirmed that the use of such a device is not permitted and that an approved release device should be used instead. Review of facility policies indicated that hazardous areas and equipment should be identified and addressed to ensure safety, and that maintenance personnel are responsible for keeping the building in compliance with regulations and free from hazards.

Plan Of Correction

Immediate Correction Action: On 5/6/25 the MS switched out the bed that was impeding the doorway closure pathway with a smaller frame bed. It no longer impedes the doorway closure pathway. On 5/5/25 the MS immediately removed the door stopper in order for _the corridor door to remain closed. Identifying Other Residents: No other rooms had this deficient practice. Measures into place: On 5/20/25 the Administrator in serviced MS and Medical Records Director on not to impede the doorway closure pathway with a door stopper or any furniture. Monitoring: During daily rounds the MS and MS assistant will visually monitor that all resident room doors will be able to and positively latch x 3 months. Also monitoring daily x 3 months that no office door be propped open with a kick down stopper. Findings will be presented to QAPI meeting quarterly for further review and/or actions if necessary. Completion date: 5/20/25 K 363

See complete original report
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