Failure to Maintain Fire Resistive Rating Due to Missing Ceiling Tiles
Penalty
Summary
Surveyors determined that the facility failed to maintain the required fire resistive rating of the building construction, specifically affecting one of two floors. During an observation, missing rated ceiling tiles were identified in the second floor IT/Conference Room. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director, who acknowledged the absence of the required ceiling tiles. No information regarding residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
Maintenance director replaced missing rated ceiling tiles in the first floor mechanical room on 8/18/2025. The Maintenance Director will conduct a facility-wide audit for any missing rated ceiling tiles and replace tiles as indicated. Maintenance director to be reeducated on policy K0161 by the NHA or Designee. Compliance will be monitored by the Maintenance Director/Designee through 5 random audits weekly x 4 for any ceiling tiles that need to be replaced. Audit results to be reviewed at the QA Committee to determine the need for further follow-up/monitoring.