Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain its sprinkler system, as evidenced by several deficiencies observed during a survey. On January 14, 2025, between 9:57 a.m. and 10:23 a.m., surveyors identified multiple issues with the sprinkler system. In the kitchen dishwashing area, a sprinkler head was found to be dirty, which could reduce its efficiency during an emergency. In the mechanical room near the boilers, wires and cables were improperly attached to the sprinkler system. Additionally, in the laundry room, sprinkler heads were observed to be dust-covered and dirty, which could also impair their functionality in an emergency. These deficiencies were confirmed by the maintenance supervisor during an interview conducted at the time of the survey.
Plan Of Correction
The sprinkler head identified was cleaned. Maintenance director advised maintenance staff that all other sprinkler heads to be reviewed and cleaned. Audits of 10 random sprinklers will be done weekly for 6 weeks to ensure cleanliness and free of debris. Audits will then be monthly thereafter.