Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain compliance with sprinkler system regulations as evidenced by two key deficiencies. Firstly, during a document review, it was found that the facility did not provide documentation for the required three-year full flow trip test of the sprinkler system. This deficiency was confirmed through an interview with the maintenance supervisor. Secondly, an observation revealed that six sprinkler heads in the laundry room were covered with dust and lint and showed signs of corrosion. This build-up of material can insulate the sprinkler's thermal element, potentially impacting its temperature activation and response time, and may lead to inadequate spray coverage. The maintenance supervisor confirmed these deficiencies during an interview.
Plan Of Correction
The sprinkler heads were cleaned on 1/31/25 in the laundry. The maintenance director received an education regarding the importance of sprinkler heads being dust-free. The sprinkler heads will be randomly monitored monthly for 4 months. The NHA will monitor system compliance monthly moving forward and report quarterly to QAPI. The three-year flow test is scheduled to be completed by vendor Granu. Report will be kept on file. The maintenance department were educated on timeliness of receiving testing and paperwork. Audit will be yearly after test completed. Results will be reviewed at QAPI for further recommendations.