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K0133
E

Deficiency in Common Wall Door Maintenance

Mechanicsburg, Pennsylvania Survey Completed on 01-23-2025

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 the integrity of common wall doors on the second floor, as observed during a survey on January 23, 2025. Specifically, the common wall door at the bridge to the elevator had gaps greater than 1/8 inch, which exceeds the allowed gap margins. This deficiency was confirmed through an interview with the Director of Maintenance, who acknowledged that the door did not meet the required standards. Additionally, another observation on the same day revealed that common wall doors on the second floor by the East Lounge also had gaps greater than 1/8 inch and lacked manual positive latching. These doors were only held closed by a coded magnetic release, which allowed them to open freely when the fire alarm was activated. The Director of Maintenance confirmed these findings, indicating that the doors did not comply with the necessary safety requirements.

Plan Of Correction

1. The distance between the common wall doors by the East lounge have been adjusted and corrected to meet one-eighth-inch requirement. 2. Door was adjusted to ensure manual positive latching. 3. Facility Maintenance Director or his designee will audit random doors for gaps for the next 3 months and then quarterly. 4. Maintenance Director will report findings to the QAPI committee.

See complete original report
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