Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its sprinkler system in accordance with NFPA 25 standards, which had the potential to affect all 131 residents. During an observation, ice buildup was found on the deflector of a sprinkler head inside the walk-in freezer. The facility was aware of this issue prior to the survey. Additionally, in the dishwashing room closet, the escutcheon plate was missing from a sprinkler, a fact also known to the facility before the survey. Further review of the facility's sprinkler system records revealed a lack of documentation for weekly inspections of the gauges for the dry sprinkler system. During an interview, the facility confirmed the absence of these records and acknowledged their inability to provide documentation of the weekly inspections during the survey.
Plan Of Correction
Element 1 This deficiency was corrected by removing the ice build up on the sprinkler head deflector located inside the walk-in freezer, replacing the escutcheon plate on the sprinkler head located in the dishwashing room closet, and performed weekly inspections of the gauges for the dry sprinkler system. Element 2 All residents have the potential to be affected by this deficiency. Element 3 A Sprinkler Head audit and Dry Sprinkler System Gauge audit are being conducted by the Maintenance Director or designee to ensure that the facility remains in compliance with K353. This audit is being completed by making rounds within the facility to ensure they are being completed. Element 4 The Sprinkler Head audit is being monitored by the Administrator or designee once a week for two months, then once every other week for two months, and then once a month for two months. The Dry Sprinkler System Gauge audit will be performed weekly on a continuous basis. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.