Sprinkler System Maintenance Deficiency Due to Missing Ceiling Tiles
Penalty
Summary
The facility failed to maintain and test the automatic sprinkler system in accordance with NFPA 25 requirements. During an observation, surveyors found missing ceiling tiles in the drop ceiling grid within the wheelchair storage room near the nurse station. This deficiency was confirmed through an interview with the Maintenance Director at the time of observation. The absence of ceiling tiles could interfere with the sprinkler system's heat collection process, as required by NFPA 25, 5.2.1. No information about specific residents, their medical history, or their condition at the time of the deficiency is provided in the report.
Plan Of Correction
The ceiling tiles in the wheelchair storage room have been installed. All other areas of the building have been inspected, and no other ceiling tiles are missing. Ceiling tiles will be inspected on a weekly basis by the maintenance department and documented in the preventative maintenance log. The Maintenance Director will monitor compliance by completing rounds weekly, observing for missing ceiling tiles.