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K0133
E

Fire Door Deficiency Due to Lack of Bottom Latching

Doylestown, Pennsylvania Survey Completed on 02-04-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain the fire resistance rating of fire doors, specifically on the first floor, where the fire door did not have a bottom latching device. This deficiency was initially observed on December 12, 2024, during an inspection at 10:00 a.m. The absence of the bottom latching was confirmed during an exit interview with the Administrator and Maintenance Director at 10:30 a.m. on the same day. During a follow-up onsite revisit conducted on February 4, 2025, between 08:15 a.m. and 11:00 a.m., it was determined that the issue had not been resolved. The component separation fire door on the first floor still lacked a bottom latching device, as confirmed in an exit interview with the Administrator at 11:00 a.m.

Plan Of Correction

The first-floor fire door bottom latching has been repaired. Maintenance staff to be educated on the importance of maintaining fire resistance rating of fire doors. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee.

See complete original report
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