Deficiencies in Hazardous Area Maintenance
Summary
The facility failed to maintain hazardous areas in compliance with safety regulations, as observed during a Life Safety Code recertification survey. Specifically, five locations within the facility were identified with deficiencies. The tub room, used for storage, was not fire-rated, had a transfer grille, and lacked a self-closing door. Similarly, the activities office, also used for storage, was not fire-rated, had a door propped open by an unapproved holder, and was not self-closing. The clean linen room had a residential doorknob that was not fire-rated, and the fire-rated label on the door was missing. Further deficiencies were noted in the therapy storage room, which had unsealed penetrations through the walls and ceiling. The kitchen dry storage room had multiple unsealed penetrations, painted-over fire ratings, and a door propped open by an unapproved holder. The facility's documentation for fire-rated smoke door assemblies was incomplete, lacking records for the clean linen door, therapy storage room, and kitchen dry storage room. The Director of Environmental Services acknowledged awareness of these deficiencies and the importance of maintaining hazardous areas for safety.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The three lifts, dining room chair, scale, fall mats, and wheelchair were removed from the tub room. The magnetic holder was removed from the door to make it self-closing. The unapproved door holder was removed from the Activity office door, and a door-closer was installed making the door self-closing. All Maintenance Employees will be educated on hazardous areas, including identifying rooms used for storage and ensuring the doors are self-closing and properly rated. The linen room doorknob was replaced with a fire-rated knob. The door will be included in the quote for recertification/replacement with an outside vendor. The Therapy Storage room unsealed penetrations through the walls and ceiling were sealed. The unapproved door holder was removed from the dry storage door. The door will be included in the quote for fire-rated recertification/replacement. The Director of Environmental Services will audit the tub room monthly with environmental rounds to ensure it is not used for storage, to ensure there are no unapproved [MEDICATION NAME] in use, and to monitor for any unsealed penetrations in the walls and sealings. The audit will be reviewed quarterly with the Quality Assurance and Performance Improvement committee for 1 year to ensure compliance. Person Responsible for Completion: Director of Environmental Services
Penalty
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