Sprinkler System Maintenance Deficiency Due to Missing Ceiling Tile
Penalty
Summary
A deficiency was identified when a ceiling tile was found missing from the drop ceiling grid in Terrace Hall above the door entering the dining area. This observation was made during a facility inspection and confirmed by interview with the Maintenance Director. The missing ceiling tile compromised the maintenance and testing requirements for the automatic sprinkler system as outlined by NFPA 25, specifically impacting the system's ability to function as intended due to the absence of a heat collector in that area. The report documents that the facility failed to ensure the sprinkler system was maintained in accordance with required standards, as evidenced by this physical deficiency.
Plan Of Correction
Element #1 The ceiling tile missing from the drop ceiling grid located on Terrace Hall above the door entering the dining room was replaced. Element #2 The ceiling tile missing from the drop ceiling grid located on Terrace Hall above the door entering the dining room was replaced. A facility-wide audit was conducted to identify and replace any additional missing drop ceiling tiles. Element #3 The EVS manager and/or designee will audit twice weekly to validate there are no missing drop ceiling tiles. The EVS facility manager will report recommendations and audit findings to the Quality Assurance Performance Improvement Committee monthly, and periodically thereafter. The Administrator will assume responsibility for attained compliance.