Hazardous Area Enclosure Deficiency
Penalty
Summary
The facility failed to maintain proper hazardous area enclosures, as evidenced by an observation on January 15, 2025. During the inspection, it was noted that the door to the storage closet in the Rehabilitation Room did not latch properly because tape was placed on the striker plate. This deficiency affected one of the eight smoke compartments in the facility. The issue was confirmed through an interview with the Facility Administrator and Assistant Maintenance Director on the same day, who acknowledged the hazardous area enclosure deficiencies.
Plan Of Correction
Tape was removed from the striker plate on the storage room doors in the rehab department. Maintenance director/designee educated rehab staff on not attaching foreign objects that would obstruct closing of any doors. Audit will be completed by maintenance director/designee weekly x 2 months and then randomly thereafter to ensure nothing is obstructing closet door from latching. Date of compliance 2/28/2025.