Deficiencies in Hazardous Area Enclosures
Penalty
Summary
The facility failed to maintain proper enclosures for three hazardous areas, affecting two of three smoke compartments. During an observation on March 17, 2025, it was noted that the door to the Clean Laundry area required adjustment to ensure it positively latched into the frame. Similarly, the door to the Medical Records area also needed adjustment for proper latching. Additionally, the door to the Oxygen Storage room in the East Wing was found not to be smoke-tight when latched into the frame, located at the nurses' station. These deficiencies were confirmed during an exit conference with the Facility Administrator and Facilities Director.
Plan Of Correction
1. The Clean Laundry, Medical Records, and East Wing Oxygen Storage room doors have been adjusted to be smoke tight and latch into the frame. 2. The Maintenance Director/Designee will check doors in the facility to ensure they are smoke tight and latch into the frame. 3. Facility doors will be randomly audited to ensure ongoing compliance. Audits will be completed by the Maintenance Director/Designee. 4. Audits will be reviewed at the facilities Q.A.P.I. meeting for review and recommendation.