Hazardous Area Door Not Maintained Closed
Penalty
Summary
Surveyors observed that the facility failed to maintain the doors of hazardous areas, specifically the electrical panel room, in a closed position when not in use. During an observation with the Maintenance Supervisor, the door to the electrical panel room was found propped open. The Maintenance Supervisor acknowledged this condition at the time of the survey. The facility's own policy and procedure for maintenance services states that the Maintenance Department is responsible for maintaining the building in compliance with all applicable laws and regulations, including ensuring that hazardous areas are properly enclosed. The deficiency was identified in one of four smoke compartments and involved a room classified as a hazardous area due to its use for storage of combustible supplies and equipment. The report does not mention any specific residents or their medical conditions in relation to this deficiency. The finding was based on direct observation, interview, and review of facility policy, with no mention of corrective actions or follow-up steps taken at the time of the survey.
Plan Of Correction
BEL VISTA HEALTHCARE CENTER makes every effort to operate in substantial compliance with Federal and State laws and regulations. Nothing in this Plan of Correction is an admission otherwise. BEL VISTA HEALTHCARE CENTER is submitting this Plan of Correction in compliance with its regulatory obligations and does not waive any objections it may have as to the merit or form of any allegations contained herein. Please note that the facility may contest the merits or form of any of the alleged deficient findings and may take reasonable steps to appeal them. This Plan of Correction constitutes BEL VISTA HEALTHCARE CENTER's written credible allegation of compliance for the deficiencies noted. It is the facility's policy to comply with all applicable federal and state regulations regarding hazardous areas enclosure requirements as specified in NFPA 101 Life Safety Code sections 19.3.2.1 and 19.3.5.9. Corrective Action Taken: On 5/20/2025, the Maintenance Supervisor immediately removed the door prop and verified proper door closure and latching operation for the electrical panel room door. The door's self-closing mechanism and latching hardware were inspected and confirmed to be functioning properly. A facility-wide inspection of all hazardous area doors was completed on 5/20/2025 to ensure proper operation of self-closing mechanisms and latching hardware. Identification of Other Areas with Potential to be Affected: On 5/20/2025, the Maintenance Director conducted a comprehensive facility-wide assessment of all hazardous areas including electrical rooms, storage rooms over 50 square feet, mechanical rooms, and other areas requiring fire-rated separation. This assessment included verification of door closure mechanisms, and latching hardware functionality. 1. Daily rounds to verify doors are unobstructed and properly closing • Monthly documented inspections of all fire-rated door assemblies. • Prohibition of door stops or other devices that prevent proper door closure. 2. Staff education was provided on 5/21/2025 regarding: • The importance of maintaining closed doors in hazardous areas. • Proper operation of fire-rated doors. • Reporting procedures for malfunctioning door hardware. Monitoring and Quality Assurance: The Maintenance Director or designee will conduct daily rounds to ensure all hazardous area doors are maintained in the closed position and functioning properly. The Maintenance Director will review compliance data monthly and report findings to the Quality Assurance and Performance Improvement (QAPI) committee. The QAPI committee will monitor compliance until substantial compliance is achieved and maintained for three consecutive months. Date of Completion: 6/12/2025