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K0225
E

Failure to Maintain Fire Resistance of Stairtower Enclosures

Lancaster, Pennsylvania Survey Completed on 04-08-2025

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 fire resistance of stairtower enclosures, which affected two of eight smoke compartments. During an observation on April 8, 2025, between 11:11 AM and 11:16 AM, it was noted that the stairtower doors in specific locations did not positively latch within their respective door frames. Specifically, at 11:11 AM, the door in Zone 4, 3rd floor Stair 1, and at 11:16 AM, the door in Zone 3, 3rd floor Stair 2, were found to be deficient. This was confirmed through an interview with the Maintenance Director, who acknowledged that the stairtower doors did not latch properly within the door frames.

Plan Of Correction

1. The zone 4, third floor stair tower 1 door was repaired on 04/11 to ensure that it latches properly. The zone 3, third floor stair tower 2 door was repaired on 04/15 to ensure that it latches properly. 2. Maintenance Director, or designee, will audit weekly for two weeks, then monthly and submit audits to monthly QAPI for review and recommendations. a. A building wide audit of the stair tower doors latching properly was completed. Audits will be done monthly to ensure stair tower doors latch properly.

See complete original report
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