Hazardous Area Enclosure Deficiencies in Shower Room
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.
Penalty
Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
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