Deficient Fire Safety in Hazardous Area
Penalty
Summary
The facility failed to maintain hazardous areas in compliance with fire safety regulations, specifically in sprinklered locations. During an observation on November 7, 2024, it was noted that the door to the West storage room on the second floor had significant damage around the latch, which failed to engage when tested. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day. A follow-up observation during an onsite revisit on January 8, 2025, revealed that the issue with the West storage room door had not been addressed. The door still exhibited significant damage around the latch, and it continued to fail to engage properly. This ongoing deficiency was again confirmed during an exit interview with the Administrator and Maintenance Director.
Plan Of Correction
In response to the deficiency of the West storage room door having significant damage around the latch and failing when tested, a new door has been ordered. We will be completing a time limited waiver by January 31, 2025.