Deficiencies in Sprinkler System Maintenance
Penalty
Summary
The facility failed to maintain its fire system sprinkler heads and ceiling smoke barriers in accordance with NFPA 101: 2012 edition and NFPA 25: 2011 edition. During a tour of the facility, several deficiencies were observed, including a missing escutcheon plate on the kitchen office sprinkler head and missing drop ceiling components in the bathrooms of rooms 122 and 126, which caused gaps near the sprinkler heads. Additionally, the storage closet by room 212 had a space along the side of the sprinkler escutcheon cap penetrating through the drop ceiling, and the second-floor dining room had two sprinkler heads missing escutcheon plates. These observations were confirmed through interviews conducted at the time of the survey. The deficiencies were communicated to the relevant staff during the Life Safety Code survey exit conference. The report highlights the potential impact of these deficiencies on all residents, as the facility did not ensure the proper maintenance of its fire protection systems.
Plan Of Correction
1. Corrective Actions Accomplished for residents found to have been affected by the deficient practice: The Maintenance Director received a proposal from the vendor for kitchen office sprinkler head (X1) and second floor dining room (X2) for escutcheons. See attached evidence. The drop ceiling was replaced in the bathroom of rooms 122 and 126 on 12/14/24. The drop ceiling was replaced in the storage closet by room 212 on 12/14/24. 2. Identification of residents who have the potential to be affected by the same deficient practice: All residents had the potential to be affected by the Sprinkler Systems. 3. Systemic changes to ensure that deficient practice does not recur: The U.S. FOIA (b) (6) was in-serviced on Sprinkler System Maintenance and Testing. The Maintenance director/designee will conduct monthly walking audits of all sprinkler systems on all floors. 4. Monitoring corrective actions: Corrective actions will be evaluated for effectiveness, and the plan of corrections will be integrated into the Quality Assurance Performance Improvement (QAPI) program. The Quality Assurance Performance Improvement Committee will review the monthly audit on a Quarterly basis x 12 months to ensure compliance.