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K0321
E

Hazardous Area Enclosure Deficiency

Drums, Pennsylvania Survey Completed on 01-22-2025

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 a hazardous area enclosure, specifically in the Soiled Utility room, which affected one of three smoke compartments. During an observation on January 22, 2025, at 11:26 a.m., it was noted that there were two unsealed penetrations in the wall around two pipes. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager on the same day at 12:30 p.m.

Plan Of Correction

The soiled utility unsealed penetrations are being sealed. A facility wide audit was conducted, and no other unsealed penetrations were found. The maintenance director was re-educated to ensure all walls are free from penetration. The NHA or designee will conduct a one-time audit to ensure soiled utility rooms are free from any wall penetration. The results will be submitted to the QAPI committee for review and analysis of the need of ongoing monitoring.

See complete original report
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