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K0353
F

Deficient Sprinkler System Maintenance Due to Missing Ceiling Tiles

Muskegon, Michigan Survey Completed on 03-26-2025

Penalty

No penalty information released
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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 and test its automatic sprinkler system in accordance with NFPA 25 requirements. During an observation on March 26, 2025, it was found that ceiling tiles were missing from the ceiling grid in the data room located in the service hall. This absence of ceiling tiles was confirmed by the facility Maintenance Director at the time of observation. The missing ceiling tiles could interfere with the proper operation of the sprinkler system, as required by the relevant fire protection standards.

Plan Of Correction

K3531. No residents were harmed as a result of this deficient practice. Ceiling tiles in the IT storage closet have been properly installed. Any protrusions through the ceiling tiles have been properly sealed with fire resistant material. The QAPI Committee has directed the Director of Plant Operations/designee to perform random audits of facility x 4 weeks to ensure ceiling tiles are in place according to NFPA 25. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.

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