Deficiencies in Facility Maintenance and Safety
Penalty
Summary
The facility was found to have deficiencies in maintaining the physical environment during a Life Safety Code recertification survey. Observations made in the basement revealed that the phone data room had a pipe leaking from the ceiling into a plastic bucket, indicating a failure to maintain the building in good repair. Additionally, the exit door #201 leading to the courtyard was observed with broken glass, further demonstrating the facility's inability to ensure a safe, healthy, functional, sanitary, and comfortable environment for residents, personnel, and the public. These issues were noted during the survey, and the Director of Building Services acknowledged the need to address them.
Plan Of Correction
Plan of Correction: Approved February 26, 2025 I. The facility immediately contacted a plumber to address the leaking pipe; the leak was repaired on 2/05/25. The Facility immediately covered the broken glass on the door leading to the courtyard, and the broken glass has since been replaced on 2/21/25. II. Anyone has the potential to be affected. To further ensure compliance and safety, all other applicable areas have been audited for leaking pipes in the ceiling and broken glass in all windows and doors. III. The maintenance department in-serviced on I310 – 415.29 physical environment on 2/12/25 by Director of Maintenance. IV. The facility created environmental audit tools to ensure a safe, healthy, functional, sanitary, and comfortable environment. Audits on the environment will be conducted biweekly for 3 months and then monthly for 3 months. V. Responsible party: Director of Maintenance/ Designee