Smoke Barrier Deficiency in Staff Lounge
Summary
The facility failed to maintain the smoke barrier in one of over ten rooms. During an observation on February 6, 2025, at 12:01 p.m., it was noted that the east wing staff lounge had loose, misaligned, broken, and non-fitting ceiling tiles, which allowed smoke to pass through. This deficiency was confirmed in an interview with the maintenance supervisor at the same time.
Plan Of Correction
The maintenance director immediately corrected the loose-fitting ceiling tiles upon discovery by the inspector. The maintenance director or designee will complete routine checks of ceiling tiles to ensure proper fit and compliance. This will be completed weekly for 3 months during environmental rounds completed by the maintenance director or designee.
Penalty
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