Hazardous Area Enclosure Deficiency
Penalty
Summary
The facility failed to maintain proper hazardous area enclosures, specifically affecting one of the three floors. During an observation on February 3, 2025, at 11:05 a.m., it was noted that the door to the copy room on the first floor was held open by an unapproved means, specifically a door wedge. This deficiency was confirmed during an interview at the exit conference with the administrator and maintenance representative on the same day at 12:15 p.m.
Plan Of Correction
1. The copy room door that was held open by an unapproved means will be repaired to proper function. 2. Additional hazardous area enclosures will be reviewed for proper function. 3. The Executive Director/ designee will educate the Maintenance Director on the importance of maintaining hazardous area enclosures to proper function in accordance with NFPA standards. 4. Any findings will be reported to the monthly QAPI Committee for further review.