Deficiencies in Hazardous Area Protection
Penalty
Summary
The facility failed to ensure that hazardous areas were adequately protected in accordance with NFPA 101:2012 Edition, Sections 19.3.2.1, 7.2.1.8, 9.7, and 8.4. During observations, it was noted that the kitchen door, which was on a hold-open device, did not close completely into its frame when released, even after multiple tests. Additionally, the storage room by the laundry had combustible boxes stored without a self-closing or automatic closing device on the door. Similarly, the dietary disposable storage room door failed to positively latch when opened to 90 degrees and released, despite repeated testing. Further observations revealed that the basement medical records room contained combustible paper records with boxes stacked throughout, and the door to this room also lacked a self-closing or automatic closing device. These deficiencies were confirmed through interviews conducted at the time of the observations. The issues were communicated to the relevant personnel during the Life Safety Code exit conference.
Plan Of Correction
1. Corrective Actions Accomplished for residents found to have been affected by the deficient practice: A self-closer was added to kitchen door and laundry storage room on 12/14/24. A latch was added to dietary disposable storage room and medical records room on 12/14/24. 2. Identification of residents who have the potential to be affected by the same deficient practice: All residents had the potential to be affected by the deficient practice. 3. Systemic changes to ensure that deficient practice does not recur: Maintenance has been serviced on protecting hazardous areas enclosures. The Maintenance Director/designee will conduct monthly walking audits of all doors within hazardous areas for compliance and tracking. Findings of audits will be submitted to the Administrator for review. 4. Monitoring corrective actions: Corrective actions will be evaluated for effectiveness, and the plan of corrections will be integrated into the Quality Assurance Performance Improvement (QAPI) program. The Quality Assurance Performance Improvement Committee will review audits on a quarterly basis for 12 months to ensure compliance.