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K0372
E

Unsealed Penetrations in Smoke Barrier Walls

Newtown Square, Pennsylvania Survey Completed on 04-17-2025

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 ensure that smoke barrier walls were free of unsealed penetrations, which is a requirement for maintaining a 1/2-hour fire resistance rating. During an observation on April 17, 2025, at 10:05 a.m., it was noted that there were unsealed penetrations above the smoke barrier doors in the trash separation room due to data lines. This deficiency was confirmed during an exit interview with the Administrator and the Director of Maintenance on the same day at 11:15 a.m.

Plan Of Correction

This penetration will be sealed with a UL approved stop gap penetration system or before 5/16/2025. Above ceiling penetrations will be made part of the Maintenance Quarterly Safety inspections by 5/16/2025. All maintenance mechanics will be inserviced on this by 5/16/2025.

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