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K0161
E

Failure to Maintain Common Wall Doors

Stevens, Pennsylvania Survey Completed on 03-31-2025

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 common wall doors to positively latch on two of two floors within the component. During an observation conducted on March 31, 2025, between 12:00 PM and 2:00 PM, it was noted that the common wall doors did not positively latch at specific locations. At 12:00 PM, the issue was observed on the upper level at the common wall between Components 01 and 02. Similarly, at 2:00 PM, the same issue was noted on the lower level at the common wall between Components 01 and 02. An interview with the Director of Maintenance at 2:20 PM on the same day confirmed the failure of the common wall doors to positively latch.

Plan Of Correction

1. The common wall doors between Components 01 and 02 have been adjusted to positively latch. 2. The corrective action was completed on 4/1/2025. 3. The Maintenance Director or Designee will conduct audits of the common wall doors between Components 01 and 02 quarterly for 1 year. 4. Findings of Audits will be submitted to QAPI for review.

See complete original report
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