Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the sprinkler system as required, affecting the entire facility. During observations on January 21, 2025, between 9:38 a.m. and 9:42 a.m., it was noted that there was storage within 18 inches of a sprinkler in multiple locations. Specifically, at 9:38 a.m., storage was observed on the first floor in the storage room across from Occupational Therapy, and at 9:42 a.m., in the storage room across from the Elevator Machine Room. This condition was observed throughout the facility. An exit interview with the Administrator and the Maintenance Director confirmed the presence of storage within 18 inches of a sprinkler.
Plan Of Correction
The items in the storage room across from the occupational therapy gym and the elevator machine room that was within 18" of the ceiling has been removed. The facility has determined that storage in the facility have the potential to be affected. The Maintenance Director in-serviced staff on ensuring that nothing gets stored within 18" from the ceiling throughout the building. The Maintenance Director will conduct weekly audits of throughout the building weekly. This audit will be completed weekly for four weeks and then monthly for three months. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.