Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the automatic sprinkler system in one location, specifically affecting one of nine smoke compartments. During an observation on January 14, 2025, at 11:45 a.m., two sprinkler heads located above the dryers in the Laundry Room were found to be dirty and dusty. The accumulation of dirt and dust on these sprinkler heads could potentially affect their activation in the event of a fire. This deficiency was confirmed during an interview with the Director of Nursing and the Maintenance Director on the same day at 2:30 p.m. The failure to maintain the cleanliness of the sprinkler heads indicates a lapse in the regular inspection and maintenance protocols as required by NFPA 25, which governs the inspection, testing, and maintenance of water-based fire protection systems.
Plan Of Correction
1. Sprinkler heads identified have been cleaned. 2. Maintenance director or designee will conduct a facility audit to verify that sprinkler heads are free from dust. 3. Nursing home administrator or designee will re-educate the maintenance director on properly maintaining the sprinkler heads in the facility verifying they are free from dust. 4. Maintenance director or designee will conduct weekly audits for four weeks and then monthly for two months thereafter to verify that the sprinkler heads are free from dust. Findings of these audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as needed. Date of compliance will be 2/18/2025.