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K0133
D

Failure to Maintain Fire Resistance of Common Walls

Oxford, Pennsylvania Survey Completed on 01-28-2025

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 of building separating common walls, which affected one of the 14 smoke compartments within the component. During an observation, it was noted that there were four unprotected penetrations in the common wall separating the 01 and 02 Components. These penetrations were located above the suspended ceiling, above the double doors, on the 01 Component side. Specifically, three penetrations were found around groups of wires, and one penetration was empty. This deficiency was confirmed through an interview with the Maintenance Manager, who acknowledged the unprotected penetrations of the fire wall.

Plan Of Correction

The four penetrations of the common wall, separating the 01 and 02 components above the suspended ceiling above the double doors will be corrected by the Maintenance Manager using an approved through penetration fire stop system. The Maintenance Manager or designee will conduct an audit of corridor walls weekly for one month. Monthly fire walls inspections will be added to PM schedule to check for penetrations and caulking in place to ensure the facility maintains the rating of the common wall. Deficient findings will be reported to DES and QAPI meeting.

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