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K0372
E

Smoke Barrier Deficiency Due to Open Penetration

Doylestown, Pennsylvania Survey Completed on 12-12-2024

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 smoke resistance of smoke barriers, which is a requirement for ensuring safety in the event of a fire. During an observation on December 12, 2024, at 9:08 a.m., it was noted that there was an open penetration by a data wire in the smoke barrier located on the third floor near resident room 304. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director later that morning at 10:30 a.m.

Plan Of Correction

Open penetration by data wire in the smoke barrier by resident room 304 was repaired using an UL approved stop gap penetration system. Maintenance staff to be educated on maintaining the smoke resistance of smoke barriers. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee.

See complete original report
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