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Based upon observation and interview, the facility failed to ensure that doors in an exit passageway, stairway enclosure, horizontal exit, smoke barrier or hazardous area were self-closing and kept in the closed position unless held open in accordance with 7.2.1.8.2 as required by 19.2.2.2.7 and 19.2.2.2.8. This deficient practice could potentially affect 6 staff and any visitors present at the time of a potential incident if smoke were allowed to pass from the Food Storage Closet into the Kitchen and corridor. Findings include:

1. On 12/2/20 at 11:36 AM, it was observed that the Food Storage Closet Door was being held open by boxes stacked in front of the door, blocking the operation of the fire door.

In an interview on 12/2/20 at 11:37 AM, Plant Operations Director (POD) #1 acknowledged that the Food Storage Closet Door was being held open by boxes stacked in front of the door, blocking the operation of the fire door.

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Based upon observation and interview, the facility failed to ensure that automatic emergency lighting of 1-1/2 hour duration is provided in accordance with 7.9 as required by 19.2.9.1. This deficient practice could affect 2 staff at the time of an emergency if the automatic emergency lighting failed to operate as designed. Findings include:

1. On 12/2/20 at 11:43 AM, it was observed that the battery-operated emergency light above Door #4 failed to operate properly when tested.

In an interview conducted on 12/2/20 at 11:44 AM, Plant Operations Director (POD) #1 verified that the battery-operated emergency light above Door #4 failed to operate properly when tested.

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