Deficiency in Hazardous Area Enclosure
Penalty
Summary
The facility failed to maintain proper hazardous area enclosures, specifically in the Laundry Room, which was found to have its door held open by unapproved means. This deficiency was observed during a survey on February 13, 2025, at 11:34 a.m., affecting one of two floors in the facility. The issue was confirmed during an exit interview with the Facility Administrator and the Facilities Manager later that day.
Plan Of Correction
This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because The Williamsport Home agrees with the allegations and citations listed on the statement of deficiencies. The Williamsport Home maintains that the alleged deficiencies do not, individually, and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as The Williamsport Home's written credible allegation of compliance. By submitting this plan of correction, The Williamsport Home does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and The Williamsport Home reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding. 1. The Laundry Room door was addressed immediately so that the door would shut properly on February 13, 2025. 2. A full house audit of doors will be completed to ensure no doors are propped open by February 28, 2025. 3. The Nursing Home Administrator or designee will conduct training/education with all staff regarding the requirement of K321 by March 7, 2025. 4. An audit on doors will be conducted weekly x 2 and then monthly x 2 by the Maintenance Director or designee. The results of the audit will be taken to monthly QA by the Maintenance Director for review.