Deficiency in Sprinkler System Maintenance
Penalty
Summary
The facility failed to maintain the automatic sprinkler protection system free from extraneous weight, which affected one of eight smoke compartments. During an observation on April 8, 2025, at 11:02 AM, it was noted that white wires were wire-tied to the sprinkler piping above the suspended ceiling in the Zone 1 Corridor, near Resident Room 412. An interview with the Maintenance Director at the same time confirmed that the wires were indeed supported by the sprinkler system.
Plan Of Correction
1. The white wires that were wire-tied to the sprinkler piping, above the suspended ceiling within Zone 1 corridor by resident room 412 was disconnected from the sprinkler piping on 04-08-2025, at time of observation. There are no wires resting on sprinkler piping. 2. Maintenance Director, or designee, will audit weekly for two weeks, then monthly for two months to ensure that the stair tower doors latch properly. Results of audits will be submitted to monthly QAPI for review and recommendations. a. Audits will be conducted whenever there is above ceiling work performed. An above ceiling process for vendors will be implemented so that when they perform above ceiling work, that the Maintenance Director will sign off there is no wiring laying on the sprinkler pipes before the vendor leaves the building.