Deficiency in Hazardous Area Enclosure
Penalty
Summary
The facility failed to comply with the requirements for hazardous area enclosures, as evidenced by the use of the ground floor Pool Area for storing multi-medical record boxes and red isolation containers. This area was not enclosed with a 1-hour fire-rated barrier as required for hazardous areas. The observation was made on April 15, 2025, at 1:50 PM, and confirmed through an interview with the Director of Maintenance at the same time. The storage of hazardous items outside a protected area indicates a deficiency in maintaining the necessary fire safety standards.
Plan Of Correction
The medical records and red isolation containers in the ground floor pool area are being moved offsite. Maintenance staff was educated on storing items in the building in 1 hour protected area only. Director of Plant Operations or designee will audit 1-time a month unused rooms in the building to ensure items are stored within a 1 hour protected area. Results will be reported at QAPI.