Unsealed Holes in Soiled Utility Room Door
Penalty
Summary
The facility failed to ensure that hazardous areas were properly maintained, specifically in the first-floor soiled utility room. During an observation, it was noted that the door to this room had three unsealed small holes. The Director of Maintenance explained that the locking mechanism on the door had broken approximately two weeks prior, and a temporary lock was installed. However, they did not realize that the existing holes in the door were not sealed when the temporary lock was put in place. This oversight is significant as it is important for hazardous area doors to be properly sealed to prevent the spread of smoke to other areas.
Plan Of Correction
Plan of Correction: Approved February 10, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Seal x3 small holes in the 1st floor soiled utility room access door. The facility will identify other residents having the potential to be affected by the same deficient practice and the following corrective action will be taken: - Audit hazardous area room doors. The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur: - Education on hazardous area enclosure provided to maintenance staff. The corrective action(s) will be monitored to ensure the deficient practice will not recur: - Audit all hazardous doors x3 months 100%. The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Director of Maintenance.