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K0225
D

Failure to Maintain Fire Resistance Rating of Stairtower Enclosures

Elizabethtown, Pennsylvania Survey Completed on 12-17-2024

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 fire resistance rating of exit stairtower enclosures, affecting two of 43 smoke compartments. On December 16, 2024, an observation revealed that the door to the Clinics South Stairtower on the 4th floor of the Roosevelt Building did not positively latch within the door frame. This issue was confirmed through an interview with the Assistant Director of Facilities and Grounds. Similarly, on December 17, 2024, it was observed that the door to the West Stairtower on the 2nd floor of the Clinics also failed to positively latch. This was again confirmed by the Assistant Director of Facilities and Grounds, indicating a compromised fire resistance rating of the stairtower.

Plan Of Correction

1. The door to the 4th floor door to the Clinics and Clinic's 2nd floor was repaired on 12/18/2024 to ensure positive latching within the door frame. 2. Maintenance staff will be educated that stair tower doors will be maintained to ensure positive latching within the door frame. General education to staff to report doors not latching for appropriate work orders. 3. The Director of Security and/or Maintenance Assistant Director or designee will monitor the building monthly to ensure that stair tower doors will positively latch within the door frame. The results of the audit will be forwarded to the Quality Assurance Committee for review and comment.

See complete original report
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