Deficient Fire Safety Measures in Hazardous Areas
Penalty
Summary
The facility failed to ensure that hazardous areas were protected in accordance with NFPA 101:2012 Edition, specifically Sections 19.3.2.1, 7.2.1.8, 9.7, 8.4, and NFPA 13. This deficiency was identified during an observation on December 20, 2024, at 11:20 AM, when it was noted that the laundry room door did not positive latch when tested. This issue was confirmed through an interview with the U.S. FOIA present at the time of the observation. The deficiency had the potential to affect all residents, as it compromised the fire safety measures required for hazardous areas. The facility's representative was informed of this deficient practice during the Life Safety Code exit conference on the same day.
Plan Of Correction
1. All residents have the potential to be affected by this deficient Life Safety Code. The laundry room door and latching mechanism were repaired by the facility maintenance department on 12/20/24. The door was then tested and confirmed to latch positively. 2. All hazardous areas were audited to confirm door and latching mechanisms were functioning properly by the maintenance department on 12/20/24. 3. The Director of Maintenance will update the maintenance schedule to include a monthly inspection of Hazardous Areas to ensure that doors are functioning properly. 4. The Safety Committee will audit all hazardous area doors for proper function and submit the results to the administrator and to the QAPI committee monthly for 3 months.