Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the automatic sprinkler system in two instances, affecting two of sixteen smoke compartments. During an observation on February 12, 2025, it was noted that the facility did not maintain storage below the 18-inch horizontal sprinkler plane in the Therapy Storage room. Additionally, there was a gap greater than 1/8 inch in a ceiling tile in the Nourishment Room on the third floor. These deficiencies were confirmed through an interview with the Facility Administrator and Maintenance Director on the same day.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. A storage in the therapy room will be moved to a lower shelf to maintain the horizontal sprinkler plane. Therapy staff will be educated on the importance of following the 18-inch rule. Random audits will be completed monthly X3. Results will be reported at the monthly Quality Assurance and Improvement meeting. Ceiling will be sealed with an approved sealant. Random audits will be completed monthly X3. Maintenance staff will be educated on the importance of maintaining a smoke/heat resistive ceiling. Results will be reported at the monthly Quality Assurance and Improvement meeting.