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: LEFFLER - Component: 02 - Tag: 0223 Based on observation and interview, it was determined the facility failed to maintain self-closing doors to self close and positively latch, to resist the passage of smoke, and to be free of obstructions from closing, in one of five smoke zones within the component.
Findings include:
1. Observation on January 22, 2024, at 12:40 PM, revealed the Leffler Kitchen doors failed to close and positively latch in frame, due to failed coordinator.
Interview at the time of the exit conference with the Administrator, Maintenance Director and Security and Transportation Supervisor on January 22, 2024, at 2:00 PM, confirmed the Kitchen doors failed to close and positively latch.
2. Observation on January 22, 2024, at 12:42 PM, revealed several penetrations in the Leffler Kitchen doors, where magnetic hardware was removed.
Interview at the time of the exit conference with the Administrator, Maintenance Director and Security and Transportation Supervisor on January 22, 2024, at 2:00 PM, confirmed the door could not resist the passage of smoke.
3. Observation on January 22, 2024, at 12:45 PM, revealed the Leffler Kitchen doors, which were equipped with self-closing devices, were held open with rubber door chocks.
Interview at the time of the exit conference with the Administrator, Maintenance Director and Security and Transportation Supervisor on January 22, 2024, at 2:00 PM, confirmed the doors were obstructed from closing.
| | Plan of Correction - To be completed: 02/16/2024
The facility submits this plan of correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges are deficient under State and Federal regulations relating to long-term care. This plan of correction should not be construed as either a waiver of the facility's right to appeal and to challenge the accuracy of the alleged deficiencies or an admission of past or ongoing violations of State or Federal regulatory requirements.
1) a. The Leffler Kitchen door will be repaired to be able to close and positively latch in the frame. b. Magnetic hardware will be put back on the doors which will eliminate the penetrations from it being removed. c. The rubber door chocks were removed so the doors could self- close. 2) Dietary staff that work in the Leffler kitchen and the maintenance department will be educated on the deficiency and how it related to the regulation 3) Audits will be done by the dietary manager or designee weekly x 8 weeks. Results of the audit will taken to the Quality Assurance committee for further recommendations. 4) Date of Completion: Feb. 16th.
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