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K0321
E

Deficient Hazardous Area Door Maintenance

Hanover, Pennsylvania Survey Completed on 02-12-2025

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 integrity of hazardous area doors in two of seven smoke compartments. During an observation, it was noted that the basement Laundry Room's rated door had gaps exceeding the allowed 3/16 inch margin. This was confirmed in an interview with the Director of Maintenance. Additionally, another observation revealed that a hazardous area door on the 1st floor, located by the elevator and Nurses' Station, did not positively latch when closed. This issue was also confirmed by the Director of Maintenance.

Plan Of Correction

1. NGP9990 fire and smoke seal will be added to door. Second door was adjusted to ensure it positively latched. 2. Facility has conducted an audit to ensure other hazardous area doors compliance with regulation. 3. Maintenance director/designee will conduct monthly inspections of doors to ensure they positively latch, and gaps are within appropriate parameters. Audits will be reviewed at QAPI to ensure compliance.

See complete original report
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