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K0321
D

Hazardous Area Enclosure Deficiency

Washington, Pennsylvania Survey Completed on 04-15-2025

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 proper hazardous area enclosures, as evidenced by an observation on April 14, 2025. During this observation, it was noted that the door to a storage room within the Inventory Control room was improperly secured open with a rope or string, preventing it from closing and latching as required. This deficiency was confirmed through an interview with the Assistant Facility Administrator and the Maintenance Director on April 15, 2025. The deficiency affected one of the fifteen smoke compartments in the facility.

Plan Of Correction

Inventory control room door was open with a rope/string, and was unable to close and latch. The rope/string was removed from the door and closed properly. Maintenance audited throughout the facility with no other door issues found. Education to be completed with all maintenance staff making sure all doors are closed properly throughout the facility. Audits will be completed by maintenance to ensure all doors are not propped open and closed properly, Weekly X4 weeks and monthly X 2. All audits will be reported to QAPI.

See complete original report
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