Smoke Barrier Deficiencies Due to Ceiling Tile Issues
Penalty
Summary
The facility failed to maintain smoke barriers in over thirty rooms, affecting the entire component. During an observation conducted on January 22, 2025, between 8:45 a.m. and 10:15 a.m., it was noted that multiple ceiling tiles on the main floor were not properly maintained. These tiles were found to be loose, misaligned, damaged, or missing in various locations. Additionally, five rooms in the basement area were impacted by a recently frozen and ruptured pipe, which caused water damage to numerous ceiling tiles. The damaged tiles were removed to address the water damage and to facilitate repairs to the piping. The absence of these ceiling tiles could potentially delay the activation of fire system components and allow smoke to pass through. The maintenance supervisor confirmed these deficiencies during an interview at the time of the survey.
Plan Of Correction
Maintenance replaced damaged and deficient ceiling tiles. Maintenance completed a whole house audit to identify deficient ceiling tiles. NHA/Designee to educate maintenance staff by 21MAR2025 on the importance of ceiling tiles to ensure proper function for smoke barrier. Maintenance/designee to complete audits weekly x 4 of ceiling tiles. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. Fire Drill conducted immediately following the safety survey. No negative findings identified.