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NY State Tag
E

Smoke Barrier Wall Deficiencies Persist in Facility

Williamsville, New York Survey Completed on 03-24-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

During a Life Safety Code survey, it was observed that smoke barrier walls in a facility were not properly maintained, affecting three of the four resident use floors. Specifically, the smoke barrier walls were incomplete from floor to ceiling/roof deck, lacked a 30-minute fire resistance rating, and had open and unsealed penetrations that could allow smoke passage. Observations revealed multiple unsealed penetrations above ceiling tiles on various floors, including outside resident rooms and in the MDS Office. These penetrations were noted to have wires and cables passing through them, which were not sealed, compromising the integrity of the smoke barriers. A follow-up Onsite Post-Survey Revisit found that the issue persisted on one of the floors, indicating a continuing deficiency. The facility's Plan of Correction had stated that the penetrations were sealed, but observations during the revisit showed otherwise. Interviews revealed that the Maintenance Director, who was responsible for implementing the Plan of Correction, was on leave, and the Maintenance Assistant was unaware of the penetrations. The Administrator, in the absence of the Maintenance Director, assumed responsibility for the Plan of Correction but was informed that the penetrations were sealed on the day they were identified, which was not the case.

Plan Of Correction

Plan of Correction: N/A Corrective action for the deficient smoke barrier on unit 4 resident room 333, MDS office on unit 2, resident room 233, and in the wall between the atrium and unit 1 have been sealed. Education will be provided to the maintenance staff on the proper procedure for checking for gaps in smoke barriers. An audit will be conducted to check all smoke barriers in the facility. This will be logged in TELS and the results will be reported to the QA committee on a monthly basis. Administrator will provide education. Weekly audits for 3 months. Reviewed monthly for 3 months in QA. Responsibility Designee - Maintenance Director.

See complete original report
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