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K0374
E

Smoke Barrier Separation Wall Deficiency

Northumberland, Pennsylvania Survey Completed on 12-16-2024

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 a smoke barrier separation wall, which affected two out of ten smoke compartments. During an observation on December 16, 2024, at 11:12 a.m., it was noted that the attic level smoke barrier separation wall door was not smoke tight when closed into the frame, specifically inside the Dietary storage area. This deficiency was confirmed during an exit interview with the Facility Administrator on the same day at 12:00 p.m.

Plan Of Correction

1. A door latch mechanism will be installed on the attic door to correct the gap and wall separation. 2. The door latch will be installed on 12/27/24. 3. Administrator / Designee will educate maintenance staff on K374 regarding smoke barrier wall separation deficiencies. 4. Maintenance staff will conduct random inspections of other similar areas to identify other potential issues. Inspections will be conducted weekly x4 weeks and results will be reported to the QA committee.

See complete original report
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