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K0321
E

Failure of Hazardous Area Door to Self-Close and Latch

Pottsville, Pennsylvania Survey Completed on 06-24-2025

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

Surveyors observed that the door to the Service Hall Food Storage Room did not self-close and latch within the door frame as required for hazardous area enclosures. The door was found dragging on the floor, which prevented it from closing and latching properly. This deficiency was confirmed during an interview with the Administrator and Maintenance Director, who acknowledged that the door failed to self-close and positively latch, thereby compromising the smoke resistance of the hazardous area enclosure in one of seven smoke compartments.

Plan Of Correction

1. The door to the Service Hall food storage room will be modified and/or replaced to allow self-closure and latching within the door frame, and repair the drag on the floor. A time-limited waiver will be requested if door replacement is required. 2. A time-limited waiver will be requested until 1/5/2026 for the door replacement in the Service Hall food storage room. Maintenance will complete monthly door checks to verify ongoing compliance with regulatory requirements, and report any negative findings to the QAPI Committee monthly. Date of compliance is 7/30/2025.

See complete original report
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