Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the automatic sprinkler system in two instances during an inspection of over 30 rooms. The first deficiency was observed in the Electrical Room/Maintenance Office, where a large gap in the ceiling tile above an electrical panel was noted. This gap could potentially allow the passage of heat and smoke, which may affect the operation of the automatic sprinkler system. The second deficiency was identified in the laundry room, where a sprinkler head was missing an escutcheon plate near the washing machines. These deficiencies were confirmed during an interview with the Facility Administrator, Maintenance Personnel, and the Plant Operations Director.
Plan Of Correction
1. The ceiling tile in the electrical/maintenance office was replaced so no gap exists. The escutcheon plate was replaced in the laundry room. 2. No further ceiling tiles were identified that had a gap. No other escutcheon plates were identified as missing. 3. The Director of Plant operations or designee will audit ceiling tiles and escutcheon plates monthly x 3 months. Audits will be taken to the safety committee and submitted to the QAPI committee for review of findings and further interventions are warranted.