Stairtower Door Gap Exceeds Allowable Limit
Penalty
No penalty information released
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 stairtower doors within the allowed gap margins on one of two floors. During an observation on January 23, 2025, at 12:10 PM, it was noted that the 2nd floor stairtower door, located by the elevator, had gaps greater than 1/8 inch. This observation was confirmed through an interview with the Director of Maintenance at the same time.
Plan Of Correction
1. The distance between the stair tower doors have been adjusted and corrected to meet one-eighth-inch requirement. 2. Facility Maintenance Director or his designee will audit random doors for gaps for the next 3 months and then quarterly. 3. Maintenance Director will report findings to the QAPI committee.