Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the automatic sprinkler system in three specific locations, affecting both floors of the building. During an observation on December 30, 2024, it was noted that there was an unsealed penetration in a ceiling tile in the janitor's closet near Resident Room B-24 on the second floor. Additionally, the transportation garage on the first floor was missing an escutcheon in the ceiling, and the janitor's closet near the East Exit on the first floor was missing a ceiling tile. These deficiencies were confirmed during an exit interview with the Facility Administrator, Facility Assistant Administrator, and a Facility Representative.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. a. The penetration in the ceiling tile in the second-floor janitor's closet, near resident room B-24 was repaired and the work was documented in work order #20321912. b. The escutcheon in the ceiling of the first-floor transportation garage will be replaced and the work will be documented in work order #20321923. c. The ceiling tile in the first-floor janitor's closet was replaced and the work was documented in work order #20321924. The Facilities Manager or his designee will maintain compliance through monthly safety rounding to identify and correct issues related to automatic sprinkler systems. All four of the corrective actions will be completed by February 4, 2025. The Facilities Manager is responsible to ensure that corrections are completed and documented in the maintenance work order program.