Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the automatic sprinkler system in three specific locations, affecting three out of six floors. During an observation on January 7, 2025, several deficiencies were noted: the make-up air room in the basement lacked a suspended ceiling assembly with surface-mounted sprinkler heads; a plastic bag material was found affixed to an automatic sprinkler head in the fifth-floor Personal Laundry; and a sprinkler head assembly in the first-floor Dietary Office was missing an escutcheon plate. These deficiencies were confirmed during an exit interview with the Facility Administrator and the Facilities Manager.
Plan Of Correction
Observation 1: The make-up air room, located at the basement level, lacked a suspended ceiling assembly (surface-mounted sprinkler heads). 1) What systematic changes will be put into place to ensure that the deficiency does not recur, and how the corrective action(s) will be monitored? The current 2 sprinkler heads in the air make-up room are scheduled to be inverted to upright heads. The remainder of the drop ceiling will be removed. Sprinkler head and in-house fire inspections will be completed quarterly. The Director of Facilities Management will report the inspection findings to the QAPI committee. Observation 2: Plastic bag material was affixed to an automatic sprinkler head, located within the fifth floor Personal Laundry. 1) What systematic changes will be put into place to ensure that the deficiency does not recur, and how the corrective action(s) will be monitored? Plastic bag material was removed from the automatic sprinkler head in the fifth floor personal laundry area. Sprinkler head and in-house fire inspections will be completed quarterly. The Director of Facilities Management will report the findings to the QAPI committee. Observation 3: A sprinkler head assembly, located within the first floor Dietary Office, lacked an escutcheon plate. 1) What systematic changes will be put into place to ensure that the deficiency does not recur, and how the corrective action(s) will be monitored? The escutcheon plate on the sprinkler assembly in the Dietary Office was replaced. Sprinkler head and in-house fire inspections will be completed quarterly. The Director of Facilities Management will report the findings to the QAPI committee.