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K0374
E

Failure to Maintain Smoke Barrier Doors

Stillwater, Pennsylvania Survey Completed on 12-23-2024

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 smoke barrier doors as required by NFPA 101 standards. During an observation on December 23, 2024, it was noted that the smoke doors near resident room B-1 had a magnetically held fire door device with a broken housing. This deficiency affected one of the two levels in the facility. The issue was confirmed during an exit interview with the Administrator and Maintenance Director on the same day.

Plan Of Correction

1. On 12/26/2024 the Maintenance Director repaired the magnetic housing device. 2. On 12/23/2024 the Maintenance Director inspected all smoke doors to verify that the magnetic housing devices were secure. 3. On 12/30/2024 the NHA educated the maintenance team on maintaining smoke barrier doors in accordance with NFPA 101 requirements. 4. The Maintenance Director/designee will conduct weekly audits for 4 weeks to verify that smoke barrier doors are in accordance with NFPA 101 requirements. Results of the audits will be reviewed at the QAPI meeting held monthly.

See complete original report
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