Fire Safety and Sprinkler System Deficiencies
Penalty
Summary
The facility was found to have deficiencies related to fire safety and sprinkler system maintenance. During an observation on April 7, 2025, at 1:00 p.m., surveyors identified an unsealed penetration surrounding red fire alarm wiring above the door in the second-floor stair tower #3. This issue was confirmed during an exit interview with the Administrator and the Maintenance Director later that day. Additionally, a document review revealed that the facility failed to maintain its sprinkler system as required. The Quarterly Sprinkler report from August 2, 2024, indicated that sprinkler gauges needed replacement by the end of 2024. However, there was no evidence of corrective action taken by the time of the survey on April 7, 2025. This lack of documentation was also confirmed during the exit interview with the facility's administration.
Plan Of Correction
Sprinkler gauges will be replaced by a qualified vendor to ensure the sprinkler system is properly maintained. Maintenance and a qualified vendor will assess sprinkler gauges throughout the facility and report findings to the Quality Council to ensure compliance.