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K0321
E

Deficiency in Hazardous Area Maintenance

Doylestown, 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 hazardous areas as required by NFPA 101 standards. During an observation on December 11, 2024, at 9:12 a.m., it was noted that the door to the trash room in the west wing did not have a self-closure device. This deficiency affects one of the two smoke compartments in the facility. The absence of a self-closure device on the door was confirmed during an exit interview with the Administrator and the Maintenance Director at 10:15 a.m. on the same day.

Plan Of Correction

Trash room on West Wing has a self-closure device. Facility ensured that the self-closure device is functioning properly. Maintenance & housekeeping will be educated on proper closure of self-closure doors & proper reporting issues. An Audit will be conducted to ensure all doors have the proper closure weekly x 4. Audit results will be reported to QAPI committee.

See complete original report
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