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K0374
E

Smoke Doors Not Closing Smoke Tight

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 smoke doors in compliance with NFPA 101 standards, specifically affecting one of the three levels. During an observation on January 13, 2025, at 10:15 a.m., it was noted that the double corridor smoke doors at room 108 did not close smoke tight. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director at the same time and date.

Plan Of Correction

Both sets of doors have been adjusted to ensure doors are smoke tight and 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 results submitted to the Quality Assurance Performance Improvement Committee on a monthly basis ongoing.

See complete original report
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