Failure to Maintain Self-Closing Fire Door Mechanism
Penalty
Summary
During a recertification survey, it was observed that the facility failed to maintain fire doors in accordance with NFPA 101 and NFPA 80 standards. Specifically, the corridor door equipped with a self-closing mechanism leading to the clean utility room by the nurse's station did not close or self-latch when tested. This observation was made during a facility tour with the Facility Manager, who confirmed the findings at the time of inspection. The deficiency was identified based on direct observation and interview, with no mention of any specific residents or patient involvement. The report notes that all fire door assemblies are required to be labeled, maintained in a legible condition, and equipped with functioning self-closing or automatic-closing devices. The failure to ensure the door's proper operation constituted noncompliance with the cited NFPA standards.
Plan Of Correction
The corridor door equipped with a self-closing mechanism leading to the clean utility room by the nurse's station was called for servicing and repairs. No residents were found to be affected by this alleged deficient practice. The Nursing Home Administrator educated the Maintenance staff on maintaining fire doors in working condition, including latching and closing appropriately. The Nursing Home Administrator/Designee will conduct weekly audits on 3 fire doors to ensure they are latching and closing appropriately for 3 months. The findings of these audits will be reported in the next risk management/Quality assurance committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring. The Nursing Home Administrator educated the Maintenance staff on maintaining fire doors in working condition, including latching and closing appropriately. The Nursing Home Administrator/Designee will conduct weekly audits on 3 fire doors to ensure they are latching and closing appropriately for 3 months. The findings of these audits will be reported in the next risk management/Quality assurance committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring.