Failure to Maintain Fire Safety in Storage Area
Penalty
Summary
The facility failed to maintain the fire rating of storage areas, specifically on the first floor near resident room 131. During an observation on November 20, 2024, it was noted that the storage room lacked a self-closing mechanism on its door, which is a requirement for maintaining the fire resistance rating of hazardous areas. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director. A follow-up observation during an onsite revisit on January 8, 2025, revealed that the deficiency had not been corrected, as the storage room near resident room 131 still lacked a self-closing door. This was again confirmed in an exit interview with the Administrator and the Regional Maintenance Director. The failure to address this issue indicates a continued non-compliance with the fire safety requirements for hazardous areas.
Plan Of Correction
Plan of Correction for TAG K321: Fire Safety - Storage Area Self-Closing Door 1. Deficiency: Based on observation and interview, it was determined that the facility failed to maintain the fire rating of storage areas, affecting one of three levels within the facility. Observation on November 20, 2024, at 10:44 a.m., revealed that on the first floor, the storage room near resident room 131 lacked a self-closing door. Exit interview with the Administrator and the Maintenance Director on November 20, 2024, at 11:00 a.m., confirmed the lack of a self-closing door. No current residents were directly affected by this deficiency; however, all residents have the potential to be affected in the event of a fire emergency if fire safety regulations are not fully met. 2. Corrective Action: The self-closing door was installed in the storage room near resident room 131 to maintain the required fire rating for the area. The Maintenance Director verified that all other storage areas are in compliance with fire safety regulations. 3. Monitoring: Weekly audits will be conducted for 4 weeks to ensure continuous compliance with fire safety regulations, including verification of the self-closing door installation and proper function. Findings will be documented, and any necessary corrective actions will be taken. 4. Timeline: The self-closing door was installed on 01/08/25. Weekly audits will be completed for 4 weeks starting from 01/28/25.