Failure to Maintain Self-Closing Door Latch
Summary
The facility failed to maintain doors with self-closing devices as required by NFPA 101 standards. During an observation, it was noted that one of the two leaves of the self-closing doors in the corridor from the 300 wing to the dining room area did not positively latch in the frame. This deficiency was confirmed through an interview with the maintenance supervisor, who acknowledged the issue with the self-closing door.
Plan Of Correction
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. 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.
Penalty
Surveyors found that a fire-rated door leading to a hazardous dry storage room, protected by a one-hour fire barrier and equipped with a self-closing device, was held open by a bungee cord and obstructed by a storage rack, preventing it from self-closing and latching as required by NFPA 101. The Administrator confirmed the door should remain closed, and the deficiency was cited based on these observations.
Surveyors observed that the clean linen closet doors near room 216 were left open and did not close to a positive latch when tested, as confirmed by maintenance staff. These doors are required to be self-closing and kept closed unless held open by an approved device, and the failure to do so resulted in a deficiency.
A corridor kitchen door equipped with a self-closing device was found not to latch when tested during a facility tour, as confirmed by the Maintenance Director. This deficiency impacted 32 residents in one smoke compartment and resulted in noncompliance with NFPA 101 standards for self-closing doors.
The facility failed to maintain two doors with self-closing devices, affecting one smoke compartment. Observations revealed that the doors at Nurse's Station 2 and Resident Room 62 did not positively latch into their frames. This issue was confirmed during an exit interview with the Facility Administrator and Facilities Manager.
The facility was found non-compliant with NFPA 101 standards as eight doors with self-closing devices were either missing door closers or held open with magnets not connected to the fire alarm system. These issues were identified during a fire safety tour and acknowledged by the Plant Operations Technician.
The facility was found non-compliant with NFPA 101 standards as a door in the Dietary Dry storage area was held open by a rubber wedge, affecting one of eight smoke compartments. This was confirmed during an exit interview with the Facility Administrator and Maintenance.
Fire-Rated Door in Hazardous Area Improperly Propped Open
Penalty
Summary
During a facility tour conducted with the Director of Maintenance (DOM) and the Administrator, surveyors observed that a fire-rated door in the kitchen exit passage leading into a hazardous dry storage room was not maintained in accordance with NFPA 101 standards. The door, which is protected by a one-hour fire barrier and equipped with a self-closing device, was found to be held open by a bungee cord wrapped around the door handle. Additionally, a storage rack was positioned in such a way that it further restricted the door from self-closing and latching as required. The Administrator, when interviewed at the time of the observation, confirmed the findings and acknowledged that the door should be kept closed. The report specifies that such doors are only permitted to be held open by an automatic release device that complies with NFPA 101 section 7.2.1.8.2, which ensures the door will close automatically upon activation of the fire alarm, sprinkler system, smoke detection system, or loss of power. In this instance, the door was not equipped with such a device and was instead manually propped open, which is not compliant with the cited regulations. No information was provided in the report regarding any residents or staff being directly affected at the time of the deficiency, nor was there mention of any medical history or specific conditions related to individuals in the facility. The deficiency was based solely on the physical observation of the door's condition and the facility's failure to maintain required fire safety standards for doors with self-closing devices in hazardous areas.
Plan Of Correction
1) No residents were identified. 2) No residents were identified. 3) Administrator immediately discarded bungee cord found to be propping fire door open on 08/04/2025. An in-service education was conducted by the Administrator, Director of Plant Operations, or designee on 08/21/2025 with staff addressing the maintaining doors with self-closing devices in accordance with NFPA 101 (2012 Edition). 4) The Director of Plant Operations, or designee, will audit at random five (5) Fire Rated Doors to observe if the door is free from devices that would prevent self-close and latch. Audits will be conducted once a week for four weeks, once a month for two months, or until substantial compliance is achieved. The results of the audit will be forwarded to the Quality Assurance Committee for review monthly for at least three months with a goal of 100% compliance. Upon completion and 100% compliance for at least three months is achieved, the frequency of further review and ongoing need for review will be determined by the QAPI committee. The same information is repeated in the original text, so it is presented here as a continuous paragraph for clarity.
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.
Failure to Maintain Self-Closing Door Latching Mechanism
Penalty
Summary
During a facility tour and interview with the Maintenance Director, it was observed that a corridor kitchen door equipped with a self-closing device did not latch when tested. The Maintenance Director acknowledged at the time of observation that he had just realized the door was not latching. This deficiency affected 32 out of 192 residents in one of six smoke compartments. The report documents that the door's failure to latch could allow the passage of smoke and gases from one part of the building to another, as the door was not maintained in accordance with NFPA 101 requirements for self-closing devices.
Plan Of Correction
K223 NFPA 101 Doors with self-closing devices How corrective action will be accomplished for those residents found to have been affected by the identified practice: Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: The door with self-closing device that did not latch when released was immediately fixed by maintenance staff. No residents were affected by the finding. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: All residents have the potential to be affected by this practice. Maintenance director and assistant conducted a sweep of all self-closing doors to ensure they latch upon release. No other findings identified. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: Maintenance staff were in serviced on June 2, 2025 by the administrator regarding policy on self-closing devices. Maintenance Director or Designee will check all self-closing devices biweekly to ensure compliance for the next 3 months. How the facility plans to monitor its performance to make sure that solutions are sustained: The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The Administrator or Designee will do rounds monthly for the next 3 months to monitor for compliance. Any issues will be reported to the Quality Assurance committee for review and recommendations. Completion date of corrective actions: June 9, 2025
Failure to Maintain Self-Closing Doors
Penalty
Summary
The facility failed to maintain two doors with self-closing devices, which affected one of six smoke compartments. During an observation on April 30, 2025, between 10:14 am and 10:21 am, it was noted that the doors did not positively latch into their frames. Specifically, the door at Nurse's Station 2 and the door of Resident Room 62, which is tied into the fire alarm system, were identified as not latching properly. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager at 11:00 am on the same day.
Plan Of Correction
The Nurse's Station 2 door and Resident Room 62 door assembly was adjusted to provide positive latching by facility maintenance department. The Maintenance Director/designee will conduct a facility wide audit to identify doors requiring adjustment to fully latch and coordinate repairs as identified. The Nursing home Administrator will provide re-education to the Maintenance Director on proper door latching requirement. The Maintenance Director will conduct audits on latching doors to verify compliance weekly x 4 weeks, then monthly x 2 months. The results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for compliance.
Non-compliance with NFPA 101: Self-Closing Door Devices
Penalty
Summary
The facility failed to maintain doors with self-closing devices in accordance with NFPA 101 standards. During a fire safety tour on April 30, 2025, it was observed that eight out of twenty-nine sampled doors with self-closing devices were not compliant. Specifically, the Beauty Supply Room and the Life Enrichment Dining Room doors were missing door closers. Additionally, several office doors, including those of the Culinary Director, Social Services, Director of Utilization, Physical Therapy, Seaway Wing Office, and Seaway Wing Clinical Services, were held open with magnets that were not connected to the fire alarm system. These deficiencies were identified during a walkthrough with the Plant Operations Technician/Director of Plant Operations, who acknowledged the findings. The issues were discussed with the Administrator and the Director of Plant Operations during the exit conference. Photographic evidence was obtained to support the observations, and the findings were documented as a Class III deficiency under NFPA 101 standards.
Plan Of Correction
No residents were affected by this alleged deficient practice as of 05/16/2025 and none can be identified as of 05/16/2025. The maintenance director and assistants were educated by the Executive Director on 05/16/2025 on K223. 1. The Beauty Supply Room 45-minute fire door, open to the corridor, was repaired and a closer was added on 05/16/2025. 2. The Culinary Director Office door, open to the corridor, had a closer added and the magnet was removed from the door frame on 05/16/2025. 3. The Social Services Office door, open to the corridor, had the magnet removed on 05/16/2025. 4. The Director of Utilization Office door, open to the corridor, had the magnet removed on 05/16/2025. 5. The Physical Therapy door, open to the corridor, had the magnet removed on 05/16/2025. 6. The Seaway Wing Office 90-minute fire rated door, open to the corridor, the magnet was removed on 05/16/2025. 7. The Seaway Wing Clinical Services 45-minute fire rated door, open to the corridor, the magnet was removed on 05/16/2025. 8. The Life Enrichment Dining Room door, open to the corridor, had a door closer installed on 05/16/2025. Doors with self-closing devices will be audited weekly x4 weeks and monthly x6 months. The repair reports and audits will be brought to QAPI on 05/21/2025 for review. No residents were affected by this alleged deficient practice as of 05/16/2025 and none can be identified as of 05/16/2025. The maintenance director and assistants were educated by the Executive Director on 05/16/2025 on K223. 1. The Beauty Supply Room 45-minute fire door, open to the corridor, was repaired and a closer was added on 05/16/2025. 2. The Culinary Director Office door, open to the corridor, had a closer added and the magnet was removed from the door frame on 05/16/2025. 3. The Social Services Office door, open to the corridor, had the magnet removed on 05/16/2025. 4. The Director of Utilization Office door, open to the corridor, had the magnet removed on 05/16/2025. 5. The Physical Therapy door, open to the corridor, had the magnet removed on 05/16/2025. 6. The Seaway Wing Office 90-minute fire rated door, open to the corridor, the magnet was removed on 05/16/2025. 7. The Seaway Wing Clinical Services 45-minute fire rated door, open to the corridor, the magnet was removed on 05/16/2025. 8. The Life Enrichment Dining Room door, open to the corridor, had a door closer installed on 05/16/2025. Doors with self-closing devices will be audited weekly x4 weeks and monthly x6 months. The repair reports and audits will be brought to QAPI on 05/21/2025 for review.
Non-compliance with Self-Closing Door Requirements
Penalty
Summary
The facility failed to maintain compliance with NFPA 101 standards regarding doors with self-closing devices. During an observation on March 19, 2025, at 10:48 a.m., it was noted that the door to the Dietary Dry storage area was being held open by an unapproved means, specifically a rubber wedge. This deficiency affected one of the eight smoke compartments within the facility. The issue was confirmed during an exit interview with the Facility Administrator and Facility Maintenance on the same day at 11:45 a.m.
Plan Of Correction
The Maintenance Director promptly took out the rubber wedge and closed the door to the dry food storage room. The facility Administrator educated both the Maintenance Director and the Food Service Director that, in accordance with life safety regulations, this door must never be propped open. To ensure compliance, the Maintenance Director will conduct weekly audits for a duration of four weeks, followed by monthly audits for three months, to verify that the dry food storage room door remains closed. The findings from these audits will be presented at the monthly Quality Assurance meeting for evaluation.
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