Ceiling Tile Gaps Compromise Flame Spread Rating Requirements
Summary
The facility failed to ensure that interior wall and ceiling finishes, specifically ceiling tiles, maintained the required flame spread rating of Class A or B, as mandated by regulations. During observations, surveyors identified 1-inch gaps between the base of exit signs and the ceiling tiles at the entrances of both the South Hall and North Hall smoke compartment doors, located near the Administrator's office and the Director of Nursing office, respectively. These deficiencies were confirmed by the Facility Maintenance Director at the time of observation. No information regarding residents' medical history or condition at the time of the deficiency is provided in the report.
Plan Of Correction
K3311. The Maintenance Director and/or designee will repair the gaps between the ceiling tiles and exit signage at the entrance of South Hall and North Hall. The Administrator will review regulation K331 and provide education to the Maintenance team on the requirements. The Maintenance Director and/or designee will conduct weekly rounds of the community to ensure no gaps in the ceiling tiles. Results of the audits will be brought to the Quality Assurance Performance Improvement meeting monthly for review. The Committee will be responsible for any changes to the auditing process. The Administrator is responsible to attain and maintain compliance. Completion date for compliance will be 06.20.25.
Penalty
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