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K0131
E

Fire Resistance Deficiency in Facility

Newtown Square, Pennsylvania Survey Completed on 01-13-2025

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 the fire resistance rating of common wall fire separations, specifically affecting one of the three levels within the facility. During an observation on January 13, 2025, at 9:00 a.m., it was noted that the rated double doors near the basement loading dock did not fully close and positively latch when tested. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director at 10:15 a.m. on the same day.

Plan Of Correction

Rated Double Door has been adjusted to ensure the doors are smoke tight, close and positively latch to maintain their fire rating. Maintenance will conduct weekly audits for 4 weeks, then monthly audits to ensure doors are smoke tight. All audits will be reviewed by The Senior Director of Property and Facilities and submitted to the Quality Assurance Performance Improvement Committee on a monthly basis for 12 months.

See complete original report
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