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K0321
E

Failure to Maintain Hazardous Area Doors

Belleville, Pennsylvania Survey Completed on 04-23-2025

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 doors of hazardous areas within the allowed gap margins and ensure they were self-closing in one of five smoke zones. During an observation on April 22, 2025, it was noted that the doors to the Mechanical Room and Storage Room in the basement exceeded the 1/8 inch gap margin and did not self-close due to faulty coordinators. This deficiency was confirmed during an exit interview with the Chief Executive Officer and Director of Campus Services on April 23, 2025.

Plan Of Correction

Mechanical room door coordinator was corrected and door gaps are being adjusted to correct gap tolerances. Storage room door gap adjusted to correct gap tolerances. Maintenance staff will be educated on proper door enclosures. An audit of hazardous area enclosures will be completed monthly for 3 months and then quarterly following. Results of the audit will be reported to the Quality Assurance Steering Committee.

See complete original report
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