Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain its automatic sprinkler system in compliance with safety standards, as observed during a Life Safety Code recertification survey. Several deficiencies were identified, including missing ceiling tiles in the third-floor north housekeeping closet, the third-floor north air handler room, and the second-floor south soiled utility room. Additionally, the second-floor south utility room had a ceiling sprinkler head missing an escutcheon, and the main kitchen had sprinkler heads with unapproved escutcheons. Damaged sprinkler heads were found in the main kitchen dish machine area, and a side-wall sprinkler head in the oxygen storage room still had its safety cover on. Furthermore, improper sprinkler heads were installed in the main kitchen emergency exit exterior pathway. The facility's quarterly sprinkler inspections did not document these deficiencies, indicating a lapse in maintenance oversight. Interviews with the Director of Maintenance revealed a lack of awareness regarding the missing ceiling tiles and sprinkler deficiencies. The Director acknowledged the importance of maintaining ceiling tiles and sprinkler systems to prevent the spread of smoke and fire. The Director also noted that the sprinkler vendor was assumed to be responsible for checking every sprinkler head during inspections, but this was not effectively done. The improper installation of high heat sprinkler heads in a non-high heat area was attributed to the vendor's responsibility, highlighting a communication gap between the facility and the vendor regarding compliance with safety standards.
Plan Of Correction
Plan of Correction: Approved February 10, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Put in ceiling tiles in the third-floor north housekeeping closet, the third-floor north air handler room, and the second-floor south soiled utility room. - Put in escutcheon for sprinkler head on second-floor south utility room. - Fix and replace main kitchen sprinkler heads (7) with unapproved escutcheons; and replace damaged sprinkler heads (3) in the main kitchen dish machine area. - Oxygen storage room sprinkler head cover removed. - Improper sprinkler heads removed and replaced in the main kitchen emergency exit exterior pathway. The facility will identify other residents having the potential to be affected by the same deficient practice and the following corrective action will be taken: - Audit ceiling tiles and sprinklers in facility. The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur: - Education on ceiling tiles to maintenance department. - Education on sprinklers to maintenance department. The corrective action(s) will be monitored to ensure the deficient practice will not recur: - Audit ceiling tiles x3 months 100%. - Audit sprinklers x2/month for 3 months 100%. The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Director of Maintenance.