Hazardous Area Enclosure Deficiency
Penalty
Summary
The facility failed to maintain proper hazardous area enclosures, specifically affecting one of the two levels of the facility. During an observation on December 16, 2024, at 11:30 a.m., it was noted that the door to the Soiled Laundry room in the E-Wing was compromised. Paper towels were found stuffed into the door frame strike plate, which prevented the door from latching properly. This deficiency was confirmed during an exit interview with the Administrator and Regional Maintenance Director on the same day at 12:45 p.m.
Plan Of Correction
This Plan of Correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in this Statement of Deficiencies. 1. The paper towel stuffed in the E-Wing Soiled Laundry Room Door has been removed. 2. Maintenance Director, or designee will conduct an initial audit of all Soiled Laundry Room doors throughout the facility to ensure that there are no additional Soiled Laundry Room doors with paper towels stuffed in the latching mechanism keeping them from properly latching. 3. Nursing and Housekeeping staff will be educated on not impeding the proper closing of doors by stuffing paper towels into the latching mechanism. 4. Maintenance Director, or designee will conduct audits, weekly x 4 weeks then monthly x 2 months of Soiled Laundry Doors to ensure paper towels are not being stuffed into the latching mechanism keeping them from properly latching. 5. Results of audits will be brought to the monthly QAPI meeting to determine if there is a need for any further action.