Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the automatic sprinkler system in six instances, affecting the entire facility. During an observation and document review, it was found that the facility did not provide documentation for the three-year Full Flow Trip Test of the dry pipe sprinkler system. Additionally, there were multiple instances of missing ceiling tiles in various rooms, including the Laundry room, Staff Development/Medical records room, kitchen, A-Wing utility room, and a gap larger than 1/8 inch in a ceiling tile inside the C-Wing Electrical Room. These deficiencies were confirmed during an interview with the Facility Administrator and Maintenance Director.
Plan Of Correction
1. The Facility will schedule the three-year Full Flow Trip Test of the dry pipe sprinkler system. 2. The facility will replace the missing ceiling tiles in the laundry room, in the staff development/medical records room, in the kitchen and in the A-wing utility room. 3. The gaps in the ceiling tile in the C-Wing Utility closet greater than 1/8 inch will be repaired/replaced as needed. 4. The maintenance staff will be in-serviced on Sprinkler system Maintenance and Testing. 5. The Maintenance staff/designee will do facility rounds to ensure all ceilings tiles are intact and that there are no gaps that are greater than 1/8 inches and will report any concerns to the Quality Assurance Performance improvement committee. 6. The Safety Committee will review the repairs to ensure all corrections are made.