Sprinkler System Maintenance Deficiency
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 the automatic sprinkler system, as evidenced by a missing ceiling tile in the Central Supply room. This deficiency was observed on April 8, 2025, at 10:50 a.m., and it was noted that the missing tile could allow the passage of heat and smoke, potentially affecting the operation of the automatic sprinkler system. This issue was confirmed during an interview with the Interim Facility Administrator and Plant Operations Manager later that day at 1:30 p.m. The deficiency impacted one of seven smoke compartments in the facility.
Plan Of Correction
1. The missing ceiling tile had no negative effect. 2. The ceiling tile in the Central Supply storage room will be replaced.