Observations
The facility failed to maintain the building in good repair. Based on a physical plant inspection on 1/13/2021, a large hole in the kitchen ceiling was observed but it did not appear to be leaking.
Interviewed staff reported the leak occurred on 11/26/2020 and was repaired 11/27/2020. The special ceiling tiles were ordered to cover the hole but they are on back order due to COVID-19 related delays
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Plan of Correction
On 1/25 the Facilities Manager confirmed that the back-ordered tiles for the kitchen, which are the required fire rated tiles, will be in stock and installed on 2/2/21.
The Facilities Manager, Project Director and Compliance Officer met to discuss the deficiency and review the maintenance request system process to determine if any improvements can be made. The Facilities Manager implemented a maintenance request system when the facility first opened back in Feb 2019. The system is working well and provides capabilities for tracking maintenance requests, time frames for completion and identify any trends. Upon review of maintenance request completed over the past 12 months, the team determined that the process works efficiently. The deficiency cited was reported on 11/26/2020 and addressed within 12 hours. The team determined that had there not been any delays from the pandemic, the ceiling tiles would have been replaced much sooner. |