Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its sprinkler system, affecting two of the four levels within the building. During observations conducted on January 22, 2025, deficiencies were noted. On the second floor, a supply closet across from resident room 270 was found to have storage items placed within 18 inches of the sprinklers, which is a violation of the required clearance for sprinkler systems. Additionally, on the ground floor, in a construction area across from the reception, several ceiling tiles were missing, potentially compromising the effectiveness of the sprinkler system. These deficiencies were confirmed during an exit interview with the Administrator and the Maintenance Director.
Plan Of Correction
Maintenance director was in serviced on having storage within 18 inches of sprinklers and on checking facility for missing ceiling tiles. Areas identified have been resolved by maintenance director by removing all storage that is within 18 inches of sprinklers and replacing missing ceiling tiles. All supply closets will be reviewed by maintenance director to assure that no storage is within 18 inches from sprinklers. All areas will be reviewed by maintenance director to assure that there are no missing ceiling tiles. Maintenance Director/ Designee will monitor all supply rooms that no storage is within 18 inches of sprinklers and that no area has missing ceiling tiles 3 times per week for 4 weeks and 1 time per month for 2 months. Results will be brought to QAPI and variances will be addressed.