Failure to Maintain Sprinkler Systems
Penalty
Summary
The facility failed to maintain automatic sprinkler systems in three locations, affecting three of eight smoke compartments. During an observation on March 19, 2025, between 10:58 a.m. and 11:25 a.m., it was found that several sprinkler heads were loaded with dust. Specifically, the sprinkler head in the 200 Hall corridor near Resident Room 201 was observed at 10:58 a.m., the sprinkler head in the 300 Hall corridor near Resident Room 303 was observed at 11:02 a.m., and the sprinkler head in the 400 Hall corridor near Resident Room 407 was observed at 11:25 a.m. An exit interview with the Facility Administrator and Facility Maintenance confirmed the presence of dust on the sprinkler heads.
Plan Of Correction
- The Maintenance Director has cleaned the dust from the sprinkler heads situated in the 200 hallway by resident room 201, the 300 hallway by resident room 303, and the 400 hallway by resident room 407. - The facility Administrator provided training to both the Maintenance Director and the Environmental Services Director on the importance of keeping these sprinkler heads dust-free at all times. - The Maintenance Director will conduct weekly audits for a duration of four weeks, followed by monthly audits for four months, and will present the findings at the monthly Quality Assurance meeting for evaluation.