Deficiencies in Sprinkler System Maintenance
Penalty
Summary
The facility failed to maintain the automatic sprinkler system, as evidenced by document review, observation, and interview. On February 6, 2025, it was found that the facility lacked documentation for quarterly or semiannual sprinkler inspections, with only one inspection completed in October 2024. Additionally, there were missing ceiling tiles in several areas, including four missing tiles in the Rehabilitation Room on the third floor, one missing tile in the maintenance supervisor's office, and four missing tiles above the Nurses Station on the seventh floor. These deficiencies were confirmed during an interview with the Facility Administrator and Maintenance Director.
Plan Of Correction
Ceiling tiles identified will be replaced by 3/21/2025. House audit for ceiling tiles was completed on February 28th, 2025. Monthly inspection of the ceiling tiles will be conducted by the Maintenance Director or designee. Quarterly and Semiannual sprinkler inspections will be conducted by 3/21/2025. The administrator or designee will reeducate Maintenance director on Sprinkler System - Testing and Maintenance -K353. Findings of sprinkler inspection and ceiling tile audit will be reported to the Quality Assurance and Performance Improvement committee meetings.