Building Construction Deficiency in Sprinkler Room
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 building construction requirements, as evidenced by an observation made on February 11, 2025. During the inspection, a penetration was found in the suspended ceiling portion of the rated ceiling assembly within the Sprinkler Room. This deficiency affects one of the four floors in the facility. The issue was confirmed during an exit interview with the Facility Administrator and Facilities Manager.
Plan Of Correction
Penetration in sprinkler room was corrected. Facility wide audit was completed for like penetrations and addressed. Maintenance will be educated re: K-0161 by NHA/Designee. Maintenance director or designee will audit all areas for 3 months and then quarterly. All findings will be reported at Monthly QPI meeting.