Smoke Barrier Deficiency in Kitchen Area
Penalty
Summary
The facility failed to maintain smoke barrier requirements in one of its three wings. During an observation on January 14, 2025, at 9:54 a.m., it was noted that the smoke barriers on the main floor, specifically in the kitchen dishwashing area, were not properly maintained. The deficiency was evidenced by the presence of missing ceiling tiles, which allowed for the transfer of smoke. This observation was confirmed through an interview with the maintenance supervisor at the same time.
Plan Of Correction
Ceiling tiles were replaced as advised. Maintenance staff educated on replacing ceiling tiles during & after providing maintenance services to ensure a proper smoke barrier. Maintenance director will audit for missing tiles weekly for 6 weeks and monthly thereafter.