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K0225
D

Fire Resistance Deficiency in Stairwell Enclosure

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 exit stairtower enclosures, specifically affecting one of the 14 smoke compartments. During an observation, it was noted that the fire exit hardware on the 1st floor Rosewood East Stairwell door was missing an end cap. This deficiency was confirmed through an interview with the Maintenance Manager, who acknowledged the compromised fire resistance of the fire exit hardware.

Plan Of Correction

1. The end cap on the fire exit hardware for Rosewood east stairwell door will be replaced. 2. The Maintenance Manager or designee will conduct an audit of the fire exit hardware weekly for one month. 3. Fire door hardware inspection will be added to the PM checklist to ensure all parts are on the fire doors. 4. Deficient findings will be reported to DES and QAPI meeting.

See complete original report
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