Deficiencies in Hazardous Area Enclosures
Penalty
Summary
The facility failed to maintain proper hazardous area enclosures in two instances, affecting two of nine smoke compartments. During an observation on December 9, 2024, it was noted that the door to the oxygen storage room on the C-2 wing lacked a self-closing device. Additionally, the door to the transfer switch room did not latch when tested. These deficiencies were confirmed through an interview with the Facility Administrator and Maintenance Director on the same day.
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. F-0321 1. Facility Maintenance director installed door closure and hardware for proper closure. 2. Facility Maintenance director/ designee conducted facility wide door audit to ensure doors had proper closure if needed. 3. Facility Maintenance director will audit doors for proper closure hardware 1x weekly x 4 weeks then monthly x 2 months.