Hazardous Area Enclosure Deficiency on Second Floor
Penalty
Summary
The facility failed to maintain a proper hazardous area enclosure on the second floor. During an observation on December 30, 2024, at 11:01 am, it was noted that the Mechanical Room had two unsealed penetrations in the concrete ceiling. This deficiency was confirmed during an exit interview with the Facility Administrator, Facility Assistant Administrator, and Facility Representative #1 on the same day at 12:30 pm.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. The penetrations in the concrete ceiling of the second-floor mechanical room were repaired and the work was documented in work order #20321914. The Facilities Manager or his designee will maintain compliance through monthly safety rounding to identify and correct issues related to hazardous area enclosures. 2. This corrective action was completed on the day of the survey. The Facilities Manager is responsible to ensure that corrections are completed and documented in the maintenance work order program.