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: ATHENS HEALTH AND REHABILITATION CENTER - Component: 01 - Tag: 0223
Based on observation and interview, it was determined the facility failed to maintain doors with self-closing devices, affecting one of two floors.
Findings include:
1. Observation on June 26, 2024, between 10:23 a.m. and 10:56 a.m., revealed the following:
a. At 10:23 a.m., the Kitchen Door, inside the dining room, was being held open by a chair.
b. At 10:56 a.m., the Laundry Door, near the time clock, was being held open by a trash can.
Exit interview with the Administrator and Maintenance Director on June 26, 2024, at 11:15 a.m., confirmed these doors being held open by unauthorized means.
| | Plan of Correction - To be completed: 07/04/2024
1. Chair and trash can were immediately removed at the time of the survey.
2. Director of Maintenance/designee will In-service Laundry and Dietary Staff on maintaining self-closing doors and not propping doors open.
3. An audit of Kitchen and Laundry door will be done daily 4x a week for 1 month and then monthly for 2 months. Results will be reviewed during monthly QAPI meeting.
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