Ceiling Tile Deficiency in Mechanical Room
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.
Penalty
Surveyors found that a generator located between the building and a parking lot had no guard posts or other approved barriers to protect it from vehicle traffic. During a revisit, the generator was still unprotected, and maintenance staff acknowledged this condition. The situation was cited as noncompliant with NFPA 1 (2021) requirements for guarding equipment subject to vehicular damage.
Generator Lacks Required Vehicle Impact Protection
Penalty
Summary
A deficiency was identified when surveyors observed that the building’s generator, located between the building and the parking lot, lacked any protective barrier from vehicle traffic. During a revisit survey, it was again noted that no guard posts or other approved protective means had been installed around the generator despite its placement in an area subject to vehicular damage. Maintenance personnel acknowledged at the time of observation that the generator remained unprotected. This condition was cited as noncompliant with NFPA 1 (2021) sections 60.5.1.9 and 60.5.1.10, which require guard posts or other approved means to protect equipment such as storage tanks, connected piping, valves, fittings, and use areas where they are subject to vehicular impact. No residents or specific patient conditions were mentioned in the report, and the deficiency focused solely on the physical environment and life safety code requirements related to the generator’s location and lack of required protective barriers.
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