Ceiling Tile Deficiency in Mechanical Room
Penalty
Summary
The facility was found to be non-compliant with NFPA 101 standards during a Life Safety tour conducted on April 22, 2025. Observations revealed that in the Mechanical room near the kitchen, 4 out of 30 ceiling tiles were either broken or missing. This deficiency was noted during the inspection at 12:36 pm, with the Maintenance Director present. The Maintenance Director acknowledged the findings during the staff interview conducted at the same time. These observations were also discussed and acknowledged by the Administrator during the exit conference. The report cites specific sections of NFPA 101 and NFPA 1 standards that were not met, indicating a failure to maintain the ceiling tiles in accordance with these safety codes.
Plan Of Correction
The 4 missing ceiling tiles were replaced by the Director of Plant Operations on 04/22/2025. An audit of the mechanical room was conducted on 04/21/2025 by the Director of Plant Operations and no other areas were missing ceiling tiles. The Regional Director of Plant Operations educated the Plant Operations department of LSC Section 18.3 and 19.3 Protection requirements to ensure compliance with protection NFPA 101. Monthly audits of the mechanical room will be completed by Plant Operations Director or designee to determine if there are any missing tiles. Findings will be taken to QAPI.