Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to meet the maintenance and testing requirements for its sprinkler system on one of two building levels. During an observation on December 19, 2024, at 10:45 a.m., it was noted that the sprinkler heads in the basement laundry room had an accumulation of dust. This accumulation can potentially delay the activation of the sprinklers during an emergency. The deficiency was confirmed through an interview with the administrator at the same time.
Plan Of Correction
Sprinkler heads in the laundry room were cleaned of dust by maintenance. Maintenance will monitor the laundry room sprinkler heads for accumulation of dust at least once a week and clean them as needed. Laundry personnel informed to notify Administration if they notice an accumulation of dust on the sprinkler heads in the laundry room. Administration will notify maintenance to clean the sprinkler heads. Administrator to monitor laundry room sprinkler heads weekly x 4 weeks and then at least monthly to ensure the sprinkler heads are free of dust. Monitoring will occur until deemed in compliance by the facility Quality Assurance and Performance Improvement Committee.