Stay Ahead of Compliance with Monthly Citation Updates


In your State Survey window and need a snapshot of your risks?

Survey Preparedness Report

One Time Fee
$79
  • Last 12 months of citation data in one tailored report
  • Pinpoint the tags driving penalties in facilities like yours
  • Jump to regulations and pathways used by surveyors
  • Access to your report within 2 hours of purchase
  • Easily share it with your team - no registration needed
Get Your Report Now →

Monthly citation updates straight to your inbox for ongoing preparation?

Monthly Citation Reports

$18.90 per month
  • Latest citation updates delivered monthly to your email
  • Citations organized by compliance areas
  • Shared automatically with your team, by area
  • Customizable for your state(s) of interest
  • Direct links to CMS documentation relevant parts
Learn more →

Save Hours of Work with AI-Powered Plan of Correction Writer


One-Time Fee

$49 per Plan of Correction
Volume discounts available – save up to 20%
  • Quickly search for approved POC from other facilities
  • Instant access
  • Intuitive interface
  • No recurring fees
  • Save hours of work
K0321
D

Deficiency in Smoke Resistance of Hazardous Area Enclosure

Oxford, Pennsylvania Survey Completed on 01-28-2025

Penalty

No penalty information released
tooltip icon
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 smoke resistance of hazardous area enclosures, specifically affecting one of the 14 smoke compartments within the component. During an observation on January 28, 2025, at 12:30 PM, it was noted that the basement door to the Maintenance Storage Room, which is over 100 square feet, lacked an automatic closure. This deficiency was confirmed through an interview with the Maintenance Manager at the same time, who acknowledged that the door did not automatically close.

Plan Of Correction

A door closure will be installed on the basement maintenance storage. The Maintenance Manager or designee will conduct a facility wide audit on hazardous doors, and then random doors on a quarterly basis. Education will be provided to all staff on when to report doors missing hardware. Deficient findings will be reported to DES and QAPI meeting.

See complete original report
An unhandled error has occurred. Reload 🗙