Deficiency in Smoke-Tight Integrity of Boiler Room Doors
Summary
The facility failed to maintain the smoke-tight integrity of hazardous area doors in one of six smoke compartments. During an observation on April 16, 2025, at 11:55 AM, it was noted that there was a gap greater than 1/2-inch between the double doors of the Boiler Room due to a removed astragal. This deficiency was confirmed during an interview with the Assistant Director of Nursing and the Maintenance Director at the exit conference on the same day at 1:45 PM.
Plan Of Correction
1 and 2. Maintenance Director installed astragal between the double doors in the boiler room. 3. Maintenance department will be educated on the standards of ensuring the facility's corridor doors do not have a gap greater than 1/2in. and to not remove astragal. 4. Maintenance or facility designee will audit the facilities corridor doors weekly x2 for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.
Penalty
Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
A faulty door closure was observed on the South Nurses' Station and Food Storage Room, resulting in the door failing to automatically close and latch as required for hazardous area enclosures. This deficiency was confirmed by the DON and Director of Maintenance.
Surveyors found that the door to a third-floor trash room, classified as a hazardous area, did not self-close or positively latch as required. This issue was confirmed by facility staff during the inspection.
Surveyors identified that hazardous area doors, including the Sprinkler Tank Room and 1st floor Dietary Storage Room, were not maintained within required gap margins and were held open with unauthorized devices, as confirmed by the Director of Facilities.
A deficiency was found when the A Hall Resident Care Supply room door did not self-close to a positive latch as required by LSC 8.7.1.3, leaving a hazardous area inadequately protected according to fire safety standards.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Deficient Fire Barrier Door Closure in Hazardous Area
Penalty
Summary
The facility failed to maintain the required fire safety standards for hazardous area enclosures in one of five smoke compartments. During an observation, it was found that the door to the South Nurses' Station and Food Storage Room did not automatically close and latch within the door frame due to a faulty door closure. This deficiency was confirmed during an interview with the Director of Nursing and the Director of Maintenance, who acknowledged that the door failed to function as required.
Plan Of Correction
1. The South Nurses Station and Food Storage Room door closure was adjusted to ensure positive latch. 2. A facility-wide audit was completed to ensure positive latch of required doors. 3. The Environmental Services Director was re-educated on the requirements of K0321. Monthly door latch audits will occur. 4. The NHA or designee will complete a random audit of facility doors weekly x 4 weeks then monthly x 2 months to ensure positive latch. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring. K 0321
Deficient Self-Closing and Latching Door in Hazardous Area
Penalty
Summary
Surveyors observed that the facility failed to ensure the door to the trash room on the third floor was self-closing and positively latching, as required for hazardous area enclosures. During the inspection, it was noted that the rated door did not close automatically or latch securely when tested. This deficiency was confirmed during an exit interview with the Maintenance Supervisor and the Director of Safety/Security, who acknowledged that the door did not function as required.
Plan Of Correction
Door has been fixed and is latching appropriately. Doors will be monitored during environmental rounds by maintenance staff.
Hazardous Area Door Deficiencies and Improper Hold-Open Devices
Penalty
Summary
The facility failed to maintain hazardous area doors in accordance with required safety standards in two of ten smoke zones. Specifically, during an observation, the Sprinkler Tank Room door (1A29D) was found to have gaps greater than 3/16 inch, which exceeds the allowed gap margins for such doors. This was confirmed by the Director of Facilities at the time of observation. Additionally, the 1st floor Dietary Storage Room rated doors (1B20) were observed being held open with manual hold-open drop downs, which are unauthorized devices. The Director of Facilities confirmed that these doors were being held open in this manner. These findings indicate that the facility did not ensure hazardous area doors were properly maintained to meet fire safety requirements.
Plan Of Correction
1. A rated door system will be installed on door 1A29D to maintain proper gap margins to less than 3/16". A recurring work order will be created to inspect the door for proper gap margins quarterly for one year. Completed work order documentation will be presented to QAPI for evaluation. 2. Manual hold open devices will be removed from doors 1B20. A recurring work order will be created to inspect doors for proper operation and positive latching quarterly for one year. Completed work order documentation will be presented to QAPI for evaluation.
Hazardous Area Door Failed to Self-Close and Latch
Penalty
Summary
A deficiency was identified when the A Hall Resident Care Supply room door was observed not to self-close to a positive latch as required by Life Safety Code (LSC) 8.7.1.3. This observation was made during a facility inspection and confirmed in an interview with a maintenance staff member. The lack of a self-closing, positively latching door in this hazardous area means the area was not properly protected as required for spaces containing combustible or hazardous materials, as outlined in LSC 19.3.2.1. The deficiency was specifically noted in relation to the protection of hazardous areas, which is necessary to prevent the spread of fire and smoke within the facility.
Plan Of Correction
Element #1: A Hall Resident Care Supply room door self-closer has been adjusted. The A Hall Resident Care Supply room door was checked to ensure the door self-closed to a positive latch. Element #2: This deficient practice has the potential to affect 15 occupants of the facility in the event of a fire not being contained to the hazardous area. Hazardous area doors in the facility have been checked and verified that they self-close to a positive latch. Doors that did not self-close to a positive latch were fixed at the time of the audit. Element #3: Nursing Home Administrator/designee has completed re-education with the Environmental Service Director on the Fire and Smoke Doors policy by the completion date. Element #4: Environmental Services Director/designee will complete audits on hazardous area doors to ensure they self-close to a positive latch. Audits will be completed weekly for four weeks and then monthly thereafter until substantial compliance is sustained. Results of the audits will be reported to facility QAPI committee for review and recommendations. This plan of correction will be monitored at the routine Quality Assurance (QAPI) meeting until such a time it is identified by the committee that sustained substantial compliance has been achieved. The Nursing Home Administrator is responsible for attaining and maintaining compliance.
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