Failure to Maintain Self-Closing Door Latching Mechanism
Penalty
Summary
During a facility tour and interview with the Maintenance Director, it was observed that a corridor kitchen door equipped with a self-closing device did not latch when tested. The Maintenance Director acknowledged at the time of observation that he had just realized the door was not latching. This deficiency affected 32 out of 192 residents in one of six smoke compartments. The report documents that the door's failure to latch could allow the passage of smoke and gases from one part of the building to another, as the door was not maintained in accordance with NFPA 101 requirements for self-closing devices.
Plan Of Correction
K223 NFPA 101 Doors with self-closing devices How corrective action will be accomplished for those residents found to have been affected by the identified practice: Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: The door with self-closing device that did not latch when released was immediately fixed by maintenance staff. No residents were affected by the finding. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: All residents have the potential to be affected by this practice. Maintenance director and assistant conducted a sweep of all self-closing doors to ensure they latch upon release. No other findings identified. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: Maintenance staff were in serviced on June 2, 2025 by the administrator regarding policy on self-closing devices. Maintenance Director or Designee will check all self-closing devices biweekly to ensure compliance for the next 3 months. How the facility plans to monitor its performance to make sure that solutions are sustained: The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The Administrator or Designee will do rounds monthly for the next 3 months to monitor for compliance. Any issues will be reported to the Quality Assurance committee for review and recommendations. Completion date of corrective actions: June 9, 2025