Failure to Maintain Automatic Sprinkler System
Penalty
Summary
The facility failed to maintain its automatic sprinkler system, as evidenced by three specific deficiencies observed during a survey. Firstly, the facility did not conduct the required first and third quarterly sprinkler inspections. Secondly, there was improper storage in the Janitor's/Housekeeping closet, where items were stored above the 18-inch horizontal sprinkler plane, potentially obstructing the sprinkler system's effectiveness. Lastly, in the Paint Room above the grease trap, two ceiling tiles were missing, which could affect the sprinkler system's performance. These deficiencies were confirmed through an interview with the Facility Administrator and Maintenance Director.
Plan Of Correction
Houskeeping/Laundry Supervisor removed storage that was higher than 18 inches from the ceiling. Maintenance Director replaced missing ceiling tiles. The Administrator will educate the Maintenance Director on requirements of K0353. Staff Development Director will educate managers on storage guideline of 18 inches below ceiling. Maintenance Director/designee will complete a round of the center to identify and correct any storage located higher than 18 inches from the ceiling or ceiling penetrations and correct deficiencies upon notation. Maintenance Director/designee will complete monthly checks for storage above 18 inches from ceiling, and ceiling penetrations, documented in TELS, ongoing. Maintenance Director will secure ongoing agreement with vendor to complete quarterly sprinkler inspections to test and maintain the centers automatic sprinkler and standpipe systems. Copies of service/inspection records will be maintained in the Life Safety Survey Preparedness Manual. Reports will be shared in the following safety committee for any additional review and or recommendations, ongoing.