Failure to Maintain Self-Closing Doors in Hazardous Area
Penalty
Summary
During an observation on June 10, 2025, at approximately 10:06 AM, surveyors found that the doors to the clean linen closet located in the 200 hall near room 216 were open and did not close to a positive latch when tested. This was confirmed through interviews with two facility maintenance staff present at the time. The doors in question are required to be self-closing and kept in the closed position unless held open by an approved release device, in accordance with regulatory standards. The failure to ensure these doors were properly self-closing and latched constituted a deficiency, as it did not comply with the requirements for doors in exit passageways, stairway enclosures, horizontal exits, smoke barriers, or hazardous area enclosures.
Plan Of Correction
Element 1 - Upon identification, environmental services staff repaired the latch to the clean linen closet located at the 200 hall near room 216. This latch now closes "per positive latch" as required. Element 2 - Environmental Services Director Designee inspected all other clean linen closet doors to assure compliance. Element 3 - The Environmental Services Director/designee will complete monthly audits for 3 months of auto latching doors to ensure compliance in accordance with NFPA 101 7.2.1.8.2. Element 4 - The Environmental Services Director/designee will report audit findings to the Quality Assurance / Performance Improvement (QAPI) Committee quarterly x 3 with further monitoring per QAPI recommendations. Any identified issues will trigger retraining and/or corrective action. Element 5 - The Nursing Home Administrator is responsible for maintaining compliance.