Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the required sprinkler systems in three specific locations, affecting four out of ten smoke compartments. During an observation on December 16, 2024, it was noted that the Environmental Service Room in Unit 3 had an unsealed penetration in the ceiling. Additionally, the Nurse's Station in Unit 3 had an unsealed gap around a sprinkler escutcheon. Furthermore, the Walk-In freezer in the Dietary area was missing an escutcheon. These deficiencies were confirmed during an exit interview with the Facility Administrator on the same day.
Plan Of Correction
1. Unsealed penetration in the ceiling of Environmental Service Room was adjusted and corrected. Sprinkler Escutcheon at station 3 nurses station causing the gap was adjusted and is back into place. Missing escutcheon for walk-in freezer has been ordered. 2. Issue in the Environmental Service Room and Nursing station 3 noted above were corrected on 12/16/24. The missing escutcheon for sprinkler head in walk-in freezer is scheduled to be replaced on 12/27/24. 3. Administrator / Designee will educate maintenance staff regarding K353 maintenance of required sprinkler systems. 4. Maintenance Staff will conduct random inspections of other smoke compartments containing sprinkler heads to identify other similar issues. Inspections will be done weekly x 4 weeks and results reported to QA committee.