Automatic Sprinkler System Deficiency Due to Unsealed Ceiling Penetrations
Penalty
Summary
The facility failed to maintain the automatic sprinkler system, as evidenced by an observation on April 22, 2025, at 12:25 p.m. During this observation, two unsealed penetrations were found in the ceiling tiles of the LTC Gym, specifically on the left side of the gym. This deficiency could potentially affect the operation of the automatic sprinkler system in one of the four smoke compartments. An interview with the Facility Administrator and Plant Operations Manager later confirmed the presence of this automatic sprinkler system deficiency.
Plan Of Correction
1. The facility replaced 2 ceiling tiles and corrected unsealed penetrations in the LTC gym on April 23, 2025. 2. Facility maintenance staff will complete visual inspection of ceiling tiles each quarter during their regular penetration inspections. The LTC Quarterly Penetration Inspection form was updated on 5/6/2025 to reflect documentation of the visual inspection. 3. Completion of visual inspection of ceiling tiles and documentation of such will be audited during the monthly Building and Safety meeting which is attended by Plant Operations Manager, Director of Environmental Services, FCMC Safety Officer, Nursing Home Administrator and Chief Operations Officer for twelve months.