Failure to Maintain Sprinkler Systems
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to maintain and inspect the sprinkler systems as required, affecting the entire facility. During an observation on December 18, 2024, at 12:40 p.m., physical damage was noted in the C wing supply closet, specifically to the ceiling grid and the sprinkler escutcheon surrounding the sprinkler head. This deficiency was confirmed during an exit interview with the Administrator, Administrator in training, and the Director of Maintenance on the same day at 1:45 p.m.
Plan Of Correction
C Wing closet repairs have been completed. Maintenance will check sprinkler heads for damage monthly times 6 months then quarterly on going. All audits will be logged in the Maintenance Audit Binder.