Deficiency in Hazardous Area Protection
Penalty
Summary
The facility was found to have a deficiency related to the protection of hazardous areas as per NFPA 101:2012 standards. During observations conducted between 8:15 AM and 3:45 PM, it was noted that the East and West wing shower rooms, which exceeded 55 square feet, were being used to store combustible materials. These rooms did not have self-closing devices on their doors, which is a requirement for hazardous areas to ensure they are properly enclosed and protected. The deficiency was confirmed through an interview with a representative present during the survey. The lack of self-closing devices on the doors of these shower rooms, which were used for storing combustibles, was identified as a failure to comply with the necessary fire safety standards. This issue had the potential to affect all 83 residents of the facility, as it compromised the fire safety measures required for hazardous areas.
Plan Of Correction
K321 - F Hazardous Areas - Enclosure Element One: A self closing device was immediately installed at the East and West wing shower rooms to protect the hazardous areas. Element Two: This deficient practice had the potential to affect all residents. Element Three: The U.S. FOIA (b) (6) was educated on the requirements regarding self closing doors for hazardous areas. Element Four: The Maintenance director / designee will audit the self closing doors monthly x3 ensuring its properly functioning. Results will be reported to the QAPI team for review.