Deficiency in Sprinkler System Maintenance
Penalty
Summary
The facility failed to maintain its automatic sprinkler system in accordance with NFPA 101 standards. During a Life Safety Survey tour, it was observed that the Rehabilitation Standpipe Room lacked a posted list in the sprinkler cabinet. Additionally, there was no spare dry sprinkler available for the freezer, nor was there a means to restore service in case of a malfunction. These deficiencies were identified during an inspection conducted at 2:43 pm on April 1, 2025, with the Maintenance Director present. The absence of essential components and documentation in the sprinkler system indicates a lapse in the facility's adherence to the required safety protocols. The Maintenance Director acknowledged these findings during the staff interview, and the issues were also discussed with the Administrator during the exit conference. The report cites specific sections of NFPA 101 and NFPA 25 that were not met, highlighting the facility's failure to comply with established fire safety standards.
Plan Of Correction
This Plan of Correction does not constitute admission or agreement by Miami Shores Nursing & Rehabilitation Center of the truth of the facts alleged, or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared solely because it is required by State and Federal Laws. **K353 Sprinkler System Maintenance and Testing** **Identify patients that were at risk and what did:** When the surveyor identified the issue we contacted vendor, and they provided the list and the director of plant operations framed it and placed it in room adjacent to the cabinet. The Dry pipe has been delivered and placed in same location. **How will you identify other patients that are at risk?** When the surveyor identified the issue, we contacted vendor, and they provided the list and the director of plant operations framed it and placed it in the room adjacent to the cabinet. The Dry pipe has been delivered and placed in same location. **Measure put in place:** The Director of Plant Operations will check monthly to ensure that the box is supplied and nothing is missing. **How will you monitor?** The Director of Plant Operations will check monthly to ensure that the box is supplied and nothing is missing. Any Variances will be brought to the QAPI Committee. 5/1/25 This Plan of Correction does not constitute admission or agreement by Miami Shores Nursing & Rehabilitation Center of the truth of the facts alleged, or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared solely because it is required by State and Federal Laws. **K353 Sprinkler System Maintenance and Testing** **Identify patients that were at risk and what did:** When the surveyor identified the issue we contacted vendor, and they provided the list and the director of plant operations framed it and placed it in room adjacent to the cabinet. The Dry pipe has been delivered and placed in same location. **How will you identify other patients that are at risk?** When the surveyor identified the issue, we contacted vendor, and they provided the list and the director of plant operations framed it and placed it in the room adjacent to the cabinet. The Dry pipe has been delivered and placed in same location. **Measure put in place:** The Director of Plant Operations will check monthly to ensure that the box is supplied and nothing is missing. **How will you monitor?** The Director of Plant Operations will check monthly to ensure that the box is supplied and nothing is missing. Any Variances will be brought to the QAPI Committee.