Smoke Barrier Deficiencies on Two Floors
Penalty
Summary
The facility failed to maintain smoke barrier requirements on two of five floors, as observed during a survey conducted on December 18, 2024. Numerous rooms, including storage, mechanical, electrical, oxygen storage, and corridors, were found to have deficiencies in their smoke barriers. Specifically, ceiling tiles were missing, broken, misaligned, sagging, deteriorated, and not fitting into the grid system. Additionally, the grid system itself was missing grid work, was in disrepair in several areas, and was not supporting the ceiling tiles. These conditions would allow the transfer of smoke, compromising the smoke barrier's effectiveness. The maintenance director confirmed these deficiencies during an interview on the same day.
Plan Of Correction
1. The smoke barriers, ceiling tiles, grid system, will be repaired on or before 1/14/2025. 2. Education will be provided to the maintenance department by Administrator or designee on the importance of maintaining smoke barrier standards. 3. Maintenance Director or designee will audit weekly x 4 weeks and monthly x 1 month. 4. Results will be discussed with QA committee with monitoring if applicable.