Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the automatic sprinkler system, affecting all three floors. During an observation on April 8, 2025, it was noted that a quarterly sprinkler inspection report from February 4, 2025, indicated that while the fire pump was operational, the control panel was nonresponsive, and the emergency stop was used to shut down the pump. This issue persisted at the time of the survey. Additionally, several deficiencies were observed: an unsealed penetration in a ceiling tile in the laundry area, five sprinkler heads in the dietary area loaded with dust, and another unsealed penetration in a corridor ceiling tile near the nurse's station on the second floor. These deficiencies were confirmed during an exit interview with the Facility Administrator and the Facilities Manager.
Plan Of Correction
1. The facilities fire pump panel will be replaced the week of May 5th 2025 with Beach Lake Sprinkler company. Maintenance has sealed the penetrations located in the laundry area. The five Dietary Sprinkler heads have been replaced. The second floor Birch penetration near the nurses' station has been sealed. 2. Maintenance Director /Designee will check the ceiling in the laundry from any additional penetrations, and seal if needed. Maintenance Director/Designee will check all sprinkler heads in the dietary for dust, and replace if needed. Maintenance/designee will inspect the Birch unit for penetrations, and seal if needed. 3. Maintenance Director /designee will complete audit x4 weeks, then monthlyx3. 4. Maintenance Director will report to QAPI audits and findings.