Deficiency in Building Construction Maintenance
Penalty
Summary
The facility failed to maintain the building construction standards as required, specifically in the ground floor accounting office storage room. During an observation, it was noted that two ceiling tiles were missing, which could potentially allow the passage of smoke and delay the activation of the sprinkler system. This deficiency was confirmed through an interview with the maintenance supervisor, who acknowledged that the ceiling tiles were missing at the time of the survey.
Plan Of Correction
1. The two ceiling tiles in the ground floor accounting office were immediately replaced at time of discovery on 12/17/2024. 2. All other ground floor storage rooms will be audited to ensure no other ceiling tiles are missing. 3. Education to be completed with maintenance team on the importance of ceiling tile placement. 4. Ceiling tiles will be monitored and reported at the next quarterly QAPI/Safety meeting by the Director of Maintenance.