Deficient Hazardous Area Door Maintenance
Penalty
Summary
The facility failed to maintain proper safety measures for hazardous area doors on two of five floors. During an observation on December 12, 2024, it was noted that several doors to hazardous areas did not latch properly or lacked self-closing capabilities. Specifically, the basement level medical waste room and the basement level elevator equipment room had doors that failed to latch in their frames. Additionally, the Business office on the ground floor contained excess combustible storage and did not have a self or automatic closing door. These deficiencies were confirmed during an exit conference with the facility's administrator, maintenance representative, and regional facility representative.
Plan Of Correction
The doors observed were fixed to ensure self-closing and positive latching. NHA educated the Maintenance Director on maintaining doors to hazardous areas. An initial audit was completed to ensure self-closing and positive latching of doors to hazardous areas. NHA/designee will audit weekly x 4, then monthly X 3. Findings will be reviewed in the monthly QAPI.