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K0321
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Hazardous Area Enclosure Deficiencies

Exeter, Pennsylvania Survey Completed on 12-10-2024

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 proper hazardous area enclosures in two specific locations, affecting one of the two floors. During an observation on December 10, 2024, it was noted that the storage room door within the Building Services Corridor was improperly held open by unapproved means, specifically being tied open. Additionally, the Laundry door was found to require adjustment to ensure it could fully latch. These deficiencies were confirmed during an exit interview with the Facility Administrator, Facilities Manager, and Regional Facilities Manager.

Plan Of Correction

- The unapproved means of holding the storage room door open was immediately removed. The laundry room door was adjusted to ensure the door closes properly. - The hazardous areas throughout the facility will be assessed to ensure doors are closed and free of unapproved means of holding the door open and doors closing properly. - Staff will be educated by Maintenance Director/designee to ensure doors to hazardous areas are not obstructed and properly closed. Maintenance Director will be educated by NHA/designee to ensure doors to hazardous areas close properly with door closures. - The doors to hazardous areas will be randomly audited monthly x3 by the maintenance director to ensure proper closure. Trends will be reviewed at QAPI meeting monthly.

See complete original report
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