Deficient Fire Sprinkler System Maintenance
Penalty
Summary
The facility failed to maintain its fire sprinkler system in accordance with NFPA 101:2012 Edition and NFPA 25:2011 Edition standards. During observations, five out of eight kitchen fire sprinkler heads and three out of six laundry fire sprinkler heads were found to be green with a coating of oxidation, with the latter also covered in lint. Additionally, a documentation review revealed that there were no records of the fire sprinkler system backflow preventer test inspections. These deficiencies were confirmed and acknowledged by the facility representative during an interview and were discussed at the Life Safety Code exit conference.
Plan Of Correction
Rose Mountain Care Center Facility ID: 3145384 Survey completion date: 12-12-2024 K353 - (F) Sprinkler System - Maintenance and Testing Element One: The sprinkler heads in the kitchen and in the laundry area that were found to be green with a coating of oxidation and covered with lint were all replaced. The facility immediately reached out to our vendor to conduct the fire sprinkler system back flow preventer test. Element Two: This deficient practice had the potential to affect all residents. Element Three: The sprinkler heads in the kitchen and in the laundry area that were found to be green with a coating of oxidation were all replaced. The [R] was educated on the requirements related to maintaining the sprinkler heads as well as the annual back flow test requirements. Element Four: The maintenance director will audit all the fire sprinkler heads in the laundry and kitchen areas ensuring proper function and maintenance monthly x3. The maintenance director will also conduct a walkthrough of the facility sprinkler heads for visual corrosion. The maintenance director will also monitor and take necessary measures on all the sprinkler reports. Results will be reported to the QAPI team for review.