Deficient Maintenance of Sprinkler Heads
Penalty
Summary
The facility failed to maintain sprinkler heads in optimal condition as required by NFPA 25. During an observation, it was found that one of the two fire sprinkler heads in the laundry exit/egress corridor had a towel with electrical tape wrapped around the pipe and sprinkler head. This observation was confirmed by the US FOIA (b)(6), who was unsure why the pipe and sprinkler head were in this condition. The deficiency was noted during an interview and observation on 10/16/24 and was discussed at the Life Safety Code exit conference on 12/12/24.
Plan Of Correction
1/17/25 1. The rag covering the sprinkler head was immediately removed on December 11, 2024. All other sprinkler heads in the Facility were visually inspected to ensure they were not covered. 2. All residents are considered at risk of sprinkler heads not meeting the requirement of the National Fire Protection Association. 3. The Maintenance, dietary, and housekeeping staff were all in-serviced on not placing any barrier in the path of any sprinkler head. The Maintenance director or designee will follow behind any vendor to ensure they do not leave any obstruction in the path of any sprinkler heads. The Director of Maintenance or designee will perform a visual inspection of all sprinkler heads on a weekly basis. 4. The Director of Maintenance or designee will report to the Administrator on the status of all sprinkler inspections at the Quarterly QA Meeting for three consecutive meetings.