Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the automatic sprinkler system, resulting in deficiencies in three of the 15 smoke compartments. During an observation on January 23, 2025, several issues were identified: a ceiling tile in the HR Copy Room was missing a portion larger than 1/8 inch, a ceiling tile in the Dietary Storage was broken and missing a corner piece, and a sprinkler head in the Chemical Storage room North stairwell was missing an escutcheon plate. These deficiencies were confirmed through an interview with the Facility Administrator and Maintenance Director on the same day.
Plan Of Correction
A. 1. Facility maintenance will repair gaps in ceiling tile in HR copy room and dietary storage greater than 1/8" with, but not limited to tighter fitting ceiling tile and/or caulking. On or before March 14, 2025. 2. Director of maintenance or designee will perform quarterly audits of facility to ensure no penetrations or gaps in ceiling. 3. Results of audit will be reviewed in QA. B. 1. Facility maintenance will install escutcheon on chemical room sprinkler head and ensure all facility sprinkler heads have the proper escutcheon plates in place on or before March 14, 2025. 2. Director of maintenance or designee will perform quarterly audits of facility to ensure escutcheon plates are in place around sprinkler heads. 3. Results of audit will be reviewed in QA.