Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the automatic sprinkler system and its components, affecting two of three floors. On January 30, 2025, observations revealed several deficiencies: on the first floor South, near the Supervisor's Office and resident room 142, sprinklers were missing escutcheon plates. Additionally, the ground floor South Sprinkler Room lacked a mounted utility box containing six spare sprinkler heads and a wrench. These issues were confirmed during an exit interview with the Administrator and the Maintenance Director. Further observations on the same day at 11:05 a.m. identified additional deficiencies on the second floor North. In the stairwell, multiple missing and damaged ceiling tiles were found near a sprinkler head, which could negatively affect the activation of the sprinkler system. This issue was also confirmed during the exit interview with the Administrator and the Maintenance Director.
Plan Of Correction
Step 1 The escutcheon plate by the supervisor's office on 1 South was replaced. The escutcheon plate by room 142 was replaced. Utility box containing six spare sprinkler heads and wrench mounted in the ground floor South Sprinkler Room. Step 2 The maintenance team was educated on the requirement to have a utility box mounted in the sprinkler room and to ensure that the Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25. Step 3 The maintenance director/ designee will audit the sprinkler room monthly x 4 to ensure that all requirements are met. Findings will be reviewed during QAPI meeting. Step 1 Ceiling tiles near the sprinkler head on the Second floor North, Stairwell replaced. Step 2 A Facility-wide audit was completed to ensure that all ceiling tiles were in good condition. Step 3 The maintenance team was educated on the requirement to ensure that ceiling tiles around sprinkler heads are in good condition and do not negatively affect the activation of the sprinkler system. Step 4 The maintenance director will complete a random audit monthly x4. Findings will be reviewed during QAPI meeting.