Stairtower 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 the stairtower doors within the allowed gap margins on two of three floors. During an observation on April 15, 2025, at 1:20 PM, it was noted that the doors on the 1st and 2nd floors of Stairtower A had gaps greater than 1/8 inch. This was confirmed in an interview with the Director of Maintenance at the same time.
Plan Of Correction
1st and 2nd Floor Stairtower A doors will be corrected to be within the allowed gap margins. Maintenance Staff were educated on Stairways and Smokeproof Enclosures. Stairways used as exits cannot have gaps greater than 1/8 gap. Director of Plant Operations or designee will audit 1 time a month. Audits will be reported at QAPI.