Mechanical Room Door Latching Failure
Penalty
Summary
The facility failed to maintain a hazardous area enclosure on one of its three floors. Specifically, during an observation on December 9, 2024, at 12:00 p.m., it was noted that the door to the 1st floor Mechanical Room did not latch into its frame when tested. This deficiency was confirmed during an exit interview with the Facility Administrator, Director of Plant Operations, and Facilities Manager later that day at 1:30 p.m.
Plan Of Correction
The statements made in this Plan of Correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To maintain compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the facilities allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. 1. The Maintenance Director corrected the 1st floor mechanical room door to ensure it latches. 2. The Maintenance Director/Designee will conduct an initial audit to verify that fire barrier doors latch appropriately. 3. Nursing Home Administrator or Designee will re-educate the Maintenance Director on proper latching of fire barrier doors. 4. The Maintenance Director/Designee will conduct weekly audits for four weeks and then monthly for two months thereafter to verify that fire barrier doors latch appropriately. This plan of correction will be reviewed at the monthly Quality Assurance Performance Improvement meeting and changes will be made as needed.