Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8
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Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0223
Based on observation and interview, the facility failed to maintain doors with self-closing devices for one of over twenty doors.
Findings include:
Observation on February 11, 2025, at 11:59 a.m., revealed the self-closing doors in the corridor from the 300 wing to the dining room area had one of two leaves fail to positively latch in the frame.
Interview with the maintenance supervisor on February 11, 2025, at 11:59 a.m., confirmed the self-closing door deficiency.
| | Plan of Correction - To be completed: 03/30/2025
This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because Communities at Indian Haven agrees with the allegations and citations listed on the statement of deficiencies. Communities at Indian Haven maintains that the alleged deficiencies do not, individually, and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Communities at Indian Haven's written credible allegation of compliance. By submitting this plan of correction, Communities at Indian Haven does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Communities at Indian Haven reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding.
K0023
1. Door on 300 wing has been adjusted. Both leaves positively latch.
2. House audit shows other doors positively latch as required.
3. Weekly checks of self closing doors will be documented by maintenance supervisor or designee ongoing.
4. A monthly random door audit will be conducted by administrator or designee for 3 months. Reviews submitted to QAPI's Safety Committee for review. Administrator to monitor for compliance.
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