Stair Tower Door Gap Deficiency
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 stair tower doors within the allowed gap margins on one of two floors. This deficiency was identified through observation and interview, indicating a lapse in maintaining the required standards for stairways and smokeproof enclosures as exits, as per NFPA 101 standards.
Plan Of Correction
1. The 1st floor stairtower doors by Resident Room 215 have been adjusted to have gaps less than 3/16 inch. 2. The corrective action was completed on 4/10/2025. 3. The Maintenance Director or Designee will conduct audits of all facility stairtower doors to have gaps less than 3/16-inch quarterly for 1 year. 4. Findings of Audits will be submitted to QAPI for review.