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K0372
E

Unsealed Penetration in Smoke Barrier Wall

Lafayette Hill, Pennsylvania Survey Completed on 12-17-2024

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 walls free of unsealed penetrations, which is a requirement for ensuring a 1/2-hour fire resistance rating. During an observation on December 17, 2024, at 12:20 p.m., a surveyor identified an unsealed penetration around a plastic pipe located on the second floor, South, above the smoke doors by reception. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 1:00 p.m.

Plan Of Correction

The facility will maintain smoke barrier walls of unsealed penetration. Per fire safety guidelines, fire caulk: 3M Fire Barrier Sealant CP 25WB+ was installed on the second-floor South penetration around the plastic pipe above the smoke doors by the reception area. Audits will be conducted once a week for 4 weeks, bi-weekly for a month to ensure compliance. The Facilities Director or designee will bring such audits to the QA meeting monthly x3 in order for the QA team to verify compliance.

See complete original report
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