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NY State Tag
D

Unsealed Hole in E-Unit Pantry Door

Morrisville, New York Survey Completed on 01-10-2025

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

During a Life Safety Code recertification survey, it was observed that the E-Unit pantry access door in the facility had an unsealed hole near the door handle. This deficiency was identified on January 8, 2025, at 11:25 AM. The Maintenance Director, during an interview on January 10, 2025, acknowledged that the door lock set for the E-Unit pantry had been replaced in 2023, but they were unaware that a hole was left from the previous door lock set until it was pointed out during the survey. The Maintenance Director emphasized the importance of ensuring that all corridor doors are properly sealed for the safety of residents and staff.

Plan Of Correction

Plan of Correction: Approved February 10, 2025 Door was repaired on 1/14/2025. Maintenance staff no longer employed. Education of Maintenance staff on importance of filling holes in doors when completing any work. The Director of Environmental Services will monitor compliance with a door audit, with a 100% threshold, and report the results to the Quality Assurance Committee quarterly.

See complete original report
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