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K0321
E

Failure of Hazardous Area Door to Self-Close and Latch

Harbor Springs, Michigan Survey Completed on 06-16-2025

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 the door to the wildflower clean linen room failed to close and positively latch during three separate tests. This observation was made during a facility inspection and was confirmed by the Maintenance Director at the time. The report specifies that hazardous areas, such as linen rooms, are required to have doors that are self-closing or automatic-closing to comply with NFPA 101 standards. The failure of the door to function as required represents noncompliance with these fire safety regulations. The deficiency could potentially affect 38 occupants in the event of a fire, as noted in the findings, but no specific details about individual residents or their medical conditions are provided in the report.

Plan Of Correction

All residents have the potential to be affected by deficient practices related to fire safety compliance. On June 16, 2025, the door to the Wildflower clean linen closet was adjusted through tightening of the door latch mechanism. Following this, the door latched properly 3 out of 3 times when tested by the Maintenance Director, as observed by the Administrator. Monitoring of door structure function and proper latching of hazardous area doors will continue to be included in regular safety rounds and on the annual door inspection completed by the Plant Operations Director, with any deficient items reported for replacement or repair.

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