Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the automatic sprinkler system, as evidenced by observations and interviews conducted during a survey. On March 17, 2025, between 10:12 a.m. and 10:20 a.m., it was observed that the West Wing had an unsealed penetration of a corridor ceiling tile near Resident Room 109, and the Med room at the Nurses' station had an unsealed penetration of the wall around two blue IT cables. Further observations between 10:39 a.m. and 10:55 a.m. revealed that the Medical Records area had two sprinkler escutcheons that had been painted over, and the East Wing Med room at the Nurses' station also had a painted-over sprinkler escutcheon. These deficiencies were confirmed during an exit conference with the Facility Administrator and Facilities Director.
Plan Of Correction
1. The ceiling tile on West Wing has been replaced. The Medication rooms IT cables have been sealed. The paint has been removed from the escutcheons in the Medical Records room. 2. The Maintenance Director/Designee will check area of the facility to ensure smoke compartments are sealed. 3. Audits of smoke compartments will be audited to ensure ongoing compliance of the automatic sprinkler system. 4. Audits will be reviewed at the facilities Q.A.P.I. meeting for review and recommendation.