Improper Conversion of Housekeeping Office to Resident Storage
Penalty
Summary
The facility failed to ensure that hazardous areas were maintained according to safety standards during a Life Safety Code recertification survey. Specifically, the housekeeping office was converted into a resident storage room without being properly rated as a hazardous storage area. During an observation, it was noted that the room, approximately 80 square feet in size, lacked a fire-rated and self-closing door assembly. In an interview, the Director of Facility Services admitted uncertainty about when the conversion occurred but acknowledged awareness of the requirement for hazardous storage rooms to be properly rated.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 The Facility Services Director or designee will remove the temporary stored items from the Housekeeping office and returning it to be an office. The Facility Services Director or designee will conduct a facility wide audit to ensure there are no other storage areas in the building that are out of compliance and if any are found to be out of compliance the storage area will be corrected in a timely manner to meet the standard. The Facility Services Director or designee will conduct an audit on a quarterly basis to inspect all storage areas in the building to ensure all other storage rooms remain in compliance with the standard. 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.