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K0225
E

Failure to Maintain Fire-Resistance Rating in Stair Towers

Lansdale, Pennsylvania Survey Completed on 04-07-2025

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 rating of stair towers, which are used as exits, affecting one of the three levels. This deficiency was identified through observation and interview, indicating non-compliance with the NFPA 101 standards for stairways and smokeproof enclosures.

Plan Of Correction

Maintenance staff sealed the penetration surrounding the red fire alarm wiring, directly above the door, at the second floor stair tower #3, using through penetration fire stop system number C-BJ-3016 with the corresponding 3M through penetration fire stop system rating 3M Fire Barrier Sealant CP 25WB+. Maintenance staff will conduct monthly audits in the stair towers to assess for unsealed penetrations and repair as needed. Audits will be presented to the Quality Council for review to ensure compliance.

See complete original report
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