Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the automatic sprinkler system, as evidenced by observations and interviews conducted on March 17, 2025. Five deficiencies were identified, affecting four out of eight smoke compartments. Specifically, items were stored within 18 inches of sprinkler heads in the Storage Room on the third floor and in a storage closet in the Physical Therapy room. Additionally, gaps greater than 1/8 inch were found in ceiling tiles in the Classroom/Storage Room and Tele-data closet in the basement, as well as in the Electric room across from the Laundry room. These deficiencies were confirmed during an interview with the Facility Administrator and Maintenance Director.
Plan Of Correction
The Nursing Home Administrator (NHA) provided re-education to the Maintenance Director on 0353 Sprinkler System. The observation 1a. The stored items within 18 inches of a sprinkler head was removed. The observation 1b. Observed gap in ceiling tile in basement classroom/storage room was repaired. The observation 1c. Observed gap in ceiling tile teledata room was repaired. The observation 1d. Observed gap in ceiling tile electric room was repaired. The observation 1e. The stored items within 18 inches of a sprinkler head was removed. The Maintenance Director/designee will perform random audits of ceiling tile to ensure no gaps greater than 1/8 inch and storage areas to ensure there are no items within 18 inches of a sprinkler head weekly times 2 weeks then monthly times 2 months.