Server Room Door Fails to Latch Properly
Summary
The facility failed to ensure that corridor doors were properly maintained, specifically the server room door, which did not close and latch properly. This deficiency was identified during an observation on January 16, 2025, at 1:11 PM, when the server room door was tested and found not to latch. During an interview on January 24, 2025, at 3:23 PM, the Director of Facility Services acknowledged awareness of the requirement for corridor doors to close and latch but was not aware of the specific issue with the server room door.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 (Corridor Doors) The Corridor door to the server room has been repaired. The door was repaired on: 1/24/25. The Facility Services Director or designee will conduct a facility-wide audit of all corridor doors throughout the building. Any deficiencies found will be corrected in a timely manner. The Facility Services Director or designee will conduct an audit for all corridor doors throughout the building on a quarterly basis. The audits will be monitored and reported to the QAPI committee on a quarterly basis. The deficiency will be corrected no later than: 3/25/25. The Facility Services Director will be responsible for this plan of correction.
Penalty
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