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, it was determined the facility failed to maintain doors with self-closing devices in one location, affecting one of two floors.
Findings include:
1. Observation on May 21, 2024, at 11:02 a.m., 300 Wing, Day/Dining Room door, needs self-closure adjustment to close door into frame.
Exit interview with the Regional Director and Maintenance Director on May 21, 2024, at 12:00 p.m., confirmed the door failed to close when tested.
| | Plan of Correction - To be completed: 06/18/2024
1. Door identified has been corrected.
2. Maintenance Director/ Designee will conduct an initial audit of the day/dining rooms in the facility to verify they close properly.
3. Nursing Home Administrator/Designee will re-educate the maintenance staff on auditing and correcting doors that fail to close properly.
4. Maintenance Director/Designee will conduct random audits of the day/dining rooms in the facility to verify they close properly weekly for four weeks and then monthly for two months thereafter. Findings of these audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes made as needed.
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