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K0374
E

Smoke Barrier Doors Failed to Close Smoke Tight

Quakertown, Pennsylvania Survey Completed on 02-10-2025

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 doors in smoke barrier walls to resist the passage of smoke in two of five smoke compartments. During an observation on February 10, 2025, it was noted that the smoke doors outside the medical records area and outside resident room 147 did not close smoke tight when tested. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day.

Plan Of Correction

1) The facility contacted an outside vendor for repair quotes on fire doors. 2) The facility will have outside vendor make repairs and a timed limited waiver was submitted for repairs to the panel. 3) The maintenance director or designee will perform weekly audits for 8 weeks, then monthly for two months, as part of a preventive maintenance plan to ensure corridor doors do not have problems closing. Results of the audit will be presented at the monthly QAPI meetings for review and or recommendations.

See complete original report
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