Deficiency in Hazardous Area Enclosures
Penalty
Summary
The facility failed to maintain proper hazardous area enclosures on one of its two levels, as observed during a survey. Specifically, all laundry room doors, approximately four in total, were found propped open with door wedges, compromising their ability to function as fire barriers. Additionally, the C wing soiled laundry room lacked a door closer, further failing to meet the required standards for hazardous area enclosures. The maintenance area also had double doors propped open with door wedges, which was confirmed during an exit interview with the Administrator, Administrator in training, and the Director of Maintenance.
Plan Of Correction
All door wedges have been removed and proper door closures will be installed by January 15th, 2025. The fire doors will be kept closed. Maintenance will audit the fire doors daily for one month, then quarterly thereafter. All audits will be kept in an audit binder.