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K0321
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Hazardous Area Enclosure Deficiencies

Beaver, Pennsylvania Survey Completed on 02-04-2025

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 proper enclosures for hazardous areas, as evidenced by observations made during a survey. Specifically, the laundry room door was found to have a gap larger than 3/4 inch at the bottom, compromising its ability to contain smoke or fire. Additionally, the closer for the basement Mechanical Room door was disconnected and hanging loosely, which could prevent the door from closing properly. The smoke doors to 3 West also had a gap larger than 3/4 inch at the bottom, and the door labeled "#1 Heat Room" was unable to close and latch in its frame. These deficiencies were confirmed through an interview with the Facility Administrator and Maintenance Director.

Plan Of Correction

321 main 1 1. The laundry room door gap greater than 3/4 of an inch was corrected. The door closer to the basement mechanical room was corrected. The smoke door gap greater than 3/4 of an inch, to 3 west, was corrected. The door labeled #1 heat room was corrected to close and latch to its frame. 2. Ongoing audits are conducted and reviewed by the Director of Maintenance or Designee to assess doors across the campus to ensure they latch to their frame, and/or have a smaller gap than 3/4 of an inch.

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