Deficiency in Sprinkler System Coverage
Penalty
Summary
The facility failed to maintain the automatic fire sprinkler system, which resulted in a deficiency affecting one of 23 smoke compartments. During an observation on January 30, 2025, at 11:20 a.m., it was noted that while there were sprinklers installed under the low bulkhead in the Therapy Break Room, there were no sprinklers on the ceiling above or in the space outside of the room. This lack of sprinkler coverage was confirmed during an interview with the Facility Administrator and Maintenance Director on the same day at 12:30 p.m.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. 1. Vendor was contacted when survey ended to schedule the service for installing the sprinklers in the designated areas in the Therapy Break Room. 2. To prevent recurrence, completion of the sprinkler installation will correct stated issue. 3. To maintain and monitor compliance, Administrator or designee will review sprinklers once completed and have them reported to monthly safety committee meeting, then turned into Monthly QAPI meeting.