Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the sprinkler system, which provides fire protection, in two instances affecting two of four floors. On December 11, 2024, at 10:19 a.m., an observation on the 1st floor in the Therapy Room revealed a missing ceiling tile near the windows. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager. Additionally, between 10:27 a.m. and 10:32 a.m., observations on the 3rd floor identified two issues: a sprinkler head in the Shower Room was not sealed into the escutcheon, creating a gap, and a gap was also found around the sprinkler escutcheon in the ceiling near the Bathing Room corridor. These sprinkler deficiencies were also confirmed during the exit interview.
Plan Of Correction
1. The missing ceiling tile in the therapy gym was replaced. The ceiling tiles around the escutcheon(s) located in the 3rd floor shower room and 3rd floor corridor outside the bathing room were corrected to eliminate the gap identified. 2. A one-time facility audit conducted to ensure no gaps were identified around other escutcheons in the facility. 3. Education to the Maintenance Director and Maintenance staff to ensure no gaps are present around any escutcheons in the facility. 4. A monthly audit will be completed for three months to ensure no gaps are present around the escutcheons in the facility. Results of audit(s) to be submitted to the QA Committee Meeting monthly.