Hazardous Area Enclosure Deficiencies in Shower Room
Penalty
Summary
Surveyors observed that the facility failed to maintain proper enclosures for hazardous areas, specifically in the Shower Room located by Room 22. The corridor door to this Shower Room was obstructed from closing by a wheeled shower bed and three soiled linen containers, each with a capacity of approximately 40 gallons. These soiled linen containers were normally stored in the Shower Room, as confirmed by staff during the survey. The obstruction prevented the door from closing, compromising the required separation of hazardous areas. Additionally, the same Shower Room door was found to be missing a self-closing mechanism. The room, measuring approximately 60 square feet, was used to store three soiled-linen containers. Staff confirmed the absence of the self-closing device and indicated they were unaware that such a mechanism was required for the door. These deficiencies affected 27 of 92 residents and one of six smoke compartments in the facility.
Plan Of Correction
* A monthly inspection of all emergency exit signage has been implemented. * Maintenance staff was trained on 4/9/25 by the Administrator on emergency lighting requirements and proper testing procedures. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system; * The Maintenance Director or designee will conduct monthly tests of all exit signage and document findings. * Any malfunctioning exit signs will be immediately repaired or replaced. * The results of inspections will be reviewed in QAPI meetings to ensure ongoing compliance. Date of Compliance 4/18/25 Tag K 321: Hazardous Areas - Enclosure How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; * The wheeled shower bed and soiled linen containers obstructing the Shower Room door by Room 22 have been removed. * A self-closing mechanism was purchased on 3/28/25. * The self-closing mechanism will be installed on the door by 4/11/25 to ensure compliance with fire safety regulations. On 4/9/25 Housekeeping and maintenance staff were trained by the Administrator on hazardous area storage regulations. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; * A facility-wide inspection was conducted by the EVS Director to ensure all hazardous area doors are unobstructed and self-closing where required. * No other issues were identified. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur; * A monthly inspection schedule has been established to verify compliance with hazardous area enclosure requirements. * The inspection will be done by the EVS director. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system; * The EVS Director or designee will perform monthly inspections of hazardous area enclosures. On 4/9/25 Housekeeping and maintenance staff were trained by the Administrator on hazardous area storage regulations. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; * A facility-wide inspection was conducted by the EVS Director to ensure all hazardous area doors are unobstructed and self-closing where required. * No other issues were identified. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur; * A monthly inspection schedule has been established to verify compliance with hazardous area enclosure requirements. * The inspection will be done by the EVS director. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system; * The EVS Director or designee will perform monthly inspections of hazardous area enclosures.