Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain its required sprinkler systems, as evidenced by observations and interviews conducted during a survey. The deficiencies were identified in five locations across three of the four floors of the facility. Specifically, on the 3rd floor, the Oxygen Storage room and a corridor near the Nurses' station were missing escutcheons. On the 1st floor, the Dietary area had an unsealed penetration of a ceiling tile near the dishwasher. In the Basement Level, the Maintenance Shop was missing an escutcheon, and the Tank Room's sprinkler box lacked a wrench for sprinkler head replacement. These deficiencies were confirmed during an exit conference with the facility administrator.
Plan Of Correction
Escutcheons were installed in the 3rd floor oxygen room, 3rd floor corridor, and maintenance shop on 2/3/2025. Ceiling tile in dietary was replaced on 1/30/2025. A sprinkler wrench was purchased and placed in the sprinkler box on 1/31/2025. The Maintenance Director audited facility sprinklers to verify escutcheons in place and ceiling tiles in the dietary department. The Maintenance Director was educated on maintaining the facility's sprinkler system by NHA. The Maintenance Director/designee will audit sprinklers to verify escutcheons are in place, the sprinkler box to verify the wrench is in place, and the dietary ceiling tiles weekly for 4 weeks and monthly for 3 months, and report findings to the monthly QAPI committee.