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K0225
E

Non-compliance with Stairtower Door Standards

West Reading, Pennsylvania Survey Completed on 12-11-2024

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 the stairtower doors in compliance with NFPA 101 standards on one of four floors. During an observation, it was noted that the 4th floor 2D stairtower door had gaps greater than the allowed 3/16 inch, which was confirmed by the Director of Maintenance. Additionally, the 4th floor 1D stairtower door had broken panic hardware, was patched, and could not be opened as it was held closed with a 2 x 4 on the stairtower side. This was also confirmed by the Director of Maintenance during the interview.

Plan Of Correction

The Maintenance Director will repair the 4th floor hallway 2D stair tower door so there is no gap greater than 3/16 inch. The Maintenance Director will secure a contractor to replace the 4th floor hallway 1D stair tower door. The facility is requesting a Time-Limited Waiver for 1D replacement to be completed no later than 5/10/2025. The Maintenance Director or Designee will audit all stair tower doors to ensure that there are no gaps greater than 3/16 inch. The Maintenance Director or Designee will audit all stair tower doors to ensure that the hardware is functioning properly. The Maintenance Director or Designee will do random monthly audits every 90 days of all stair tower doors to ensure that there are no gaps greater than 3/16 inch and that the hardware is functioning properly. The Maintenance Director or Designee will present findings at the QAPI meetings for review and/or recommendations.

See complete original report
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