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K0321
D

Hazardous Area Enclosure Deficiency in Smoke Compartment

Pittsburgh, Pennsylvania Survey Completed on 01-29-2025

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 hazardous area enclosures, as evidenced by an observation on January 29, 2025, at 11:45 a.m. The surveyor identified two penetrations in the walls of the Housekeeping/Data closet, specifically in Room 607. This deficiency affected one of the 13 smoke compartments within the facility. During an interview conducted on the same day at 1:00 p.m., both the Facility Administrator and the Maintenance Director confirmed the presence of the hazardous area enclosure deficiency.

Plan Of Correction

The two penetrations were fixed in the housekeeping/data closet (607) on January 30th, 2025. Each data closet will be inspected monthly for any new penetrations. Results will be reported to the quality assurance and performance improvement committee.

See complete original report
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