Building Construction Deficiency: Missing Ceiling Tiles
Penalty
Summary
The facility failed to maintain building construction requirements, as evidenced by an observation on December 30, 2024. During the inspection, it was noted that the ceiling tiles were missing in two locations within the first floor Maintenance Storage Room. This deficiency affected one of the nine smoke compartments in the facility. The issue was confirmed during an exit interview with the Facility Administrator on the same day.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance. 1. Both ceiling tiles were replaced with a rated ceiling tile. 2. Other ceiling tiles will be checked to ensure they are in place. 3. Maintenance will be re-educated on ensuring that ceiling tiles are in place. 4. Maintenance Director/ designee will conduct random audits to verify that ceiling tiles are in place weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at QAPI meeting for review and recommendations.