Deficiencies in Hazardous Area Door Maintenance
Penalty
Summary
The facility was found to have deficiencies in maintaining the safety of hazardous areas, as evidenced by the failure of certain doors to self-close and positively latch. During an observation on February 4, 2025, at 12:15 PM, it was noted that the right leaf of the 'Dock Area' door did not self-close due to the absence of a self-closing device. This deficiency was confirmed during an interview with the Acting Administrator and Director of Maintenance later that day. Additionally, another observation at 12:20 PM on the same day revealed that the Kitchen Storage door failed to positively latch because it lacked a lock cylinder. This issue was also confirmed during the exit conference with the facility's administration and maintenance leadership. These deficiencies affected two of the six smoke zones within the facility, indicating a failure to comply with the required fire safety standards for hazardous areas.
Plan Of Correction
Self-closing device and a magnetic lock will be added to the dock door. Lock cylinder will be added to the kitchen storage door. I am requesting a time limited waiver for this self-closing device and magnetic lock due to the hardware not being here until after 3/24/25. I sent you a letter requesting the TLW. The dock door work will be completed by 8/1/25. All hazardous areas will have a self-closing device to the doors. 3. Maintenance staff will be educated on Hazardous areas within the building needing self-closing devices. 4. A quarterly audit will occur for all hazardous areas having self-closing devices. The Audit will address hazardous doors self-closing and positively latch. Audit results will be reviewed at the next QAPI meeting.