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K0225
F

Failure to Maintain Stairtower Door Gap Margins

Pottstown, Pennsylvania Survey Completed on 12-09-2024

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 stairtower doors within the allowed gap margins, as required by NFPA 101 standards for stairways and smokeproof enclosures. During an observation on October 8, 2024, it was noted that the stairtower doors on both the basement and the 1st floor had gaps greater than one eighth of an inch. This deficiency was confirmed through an interview with the Director of Maintenance. A follow-up observation on December 9, 2024, revealed that the issue had not been corrected, which was again confirmed by the Director of Maintenance.

Plan Of Correction

1. The facility is unable to retroactively ensure stair tower door gaps are within the allowed margin. 2. Facility-wide audit of all stair tower doors conducted. The basement and first floor stair tower doors will be adjusted to ensure gaps are less than one eighth of an inch. 3. Audits will be conducted monthly for 3 months then quarterly for 3 quarters. Results of the audits will be presented to our QAPI committee for review and analysis of need for ongoing monitoring.

See complete original report
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