Smoke Barrier Deficiencies in Facility
Penalty
Summary
The facility failed to maintain smoke barrier requirements in two of over ten rooms, as observed during a survey on January 15, 2025. Specifically, deficiencies were noted in the main floor emergency stock room, where ceiling tiles were found to be loose and missing. Additionally, the third floor roof access room had loose, missing, and unsealed ceiling tiles. These observations were confirmed through an interview with the maintenance supervisor conducted at the time of the survey.
Plan Of Correction
1. Missing ceiling tiles were replaced in the emergency stock room. 2. Third floor roof access room loose and ensealed ceiling tiles were replaced and repaired. 3. Facility maintenance/NHA will audit ceiling tiles weekly times 4 weeks then monthly times 2 months.