Hazardous Area Enclosure Deficiency
Penalty
Summary
The facility failed to maintain a hazardous area enclosure, specifically the Trash Room door on the first floor, which was not smoke-tight. This deficiency was identified during an observation conducted on December 23, 2024, at 10:53 a.m. The issue was confirmed during an exit interview with the Facility Administrator and the Facilities Manager later that day. The deficiency affects one of the two floors in the facility, indicating a failure to comply with the requirements for hazardous area enclosures as outlined in NFPA 101 standards.
Plan Of Correction
The first floor Trash Room door was corrected and made smoke tight. Hazardous area doors were audited and are all smoke tight. NHA/Designee educated the Maintenance Director on NFPA 101 Hazardous Area-Enclosures. Maintenance Director will randomly audit Hazardous area doors 1x week for 4 weeks then monthly x2.