Failure to Maintain Sprinkler System Due to Missing Ceiling Tile
Penalty
Summary
The facility failed to maintain the automatic sprinkler system as required, as evidenced by an observation of a missing ceiling tile in the Physical Therapist's office, located in the Patient Therapy room. This opening in the ceiling could allow the passage of heat and smoke, which may affect the operation of the automatic sprinkler system. The deficiency was confirmed during an interview with the Facility Administrator and the Maintenance Director. The issue was identified in one of five smoke compartments within the facility. No information regarding specific patients, their medical history, or their condition at the time of the deficiency is provided in the report.
Plan Of Correction
The automatic sprinkler system is now maintained in the facility in all five smoke compartments. The Maintenance Director replaced the missing ceiling tiles in the Physical Therapist's office and in the Patient Therapy room, ensuring there are no current openings in the ceiling, preventing the passage of heat and smoke, and ensuring correct operation of the automatic sprinkler system. The Maintenance Director/designee will complete a check for missing ceiling tiles monthly for three months, ensuring compliance and no automatic sprinkler system deficiency. Findings will be reviewed at monthly Quality Assurance Meetings.