Inadequate Maintenance of Sprinkler System
Penalty
Summary
The facility's automatic sprinkler system was found to be inadequately maintained during a Life Safety Code survey. Observations revealed that numerous sprinkler heads across the facility, including those in the Cedar Unit Tub room, dining room, lounge, Therapy Suite, and various other locations, were loaded and covered with lint, dust, and debris. Some sprinkler heads were also corroded and rusted, requiring replacement. Additionally, an escutcheon was missing from a sprinkler head in the walk-in freezer. The facility lacked documentation verifying that quarterly inspections, testing, and maintenance of the sprinkler system had been completed, and the post indicator valve was seized in the open position. Further inspection above the ceiling tiles on both the first and second floors revealed that sprinkler piping and pipe hangers were improperly used to support external loads, such as temporary lighting, electrical wiring, and junction boxes. These items were attached to the sprinkler system using metal wires and plastic ties, which is not compliant with safety standards. The Maintenance Supervisor acknowledged that the facility did not have documentation for checks conducted on the sprinkler piping when maintenance work was performed above the ceiling tiles. Interviews with the Maintenance Supervisor revealed that the facility had no documentation for the inspection and testing of the automatic sprinkler system for the second quarter of 2023 and the third quarter of 2024. The contractor responsible for inspecting, testing, and maintaining the system did not perform these tasks during the specified periods. Additionally, issues documented in the contractor's inspection reports from October 2024 and January 2025, such as dirty and corroded sprinkler heads in the kitchen, were not addressed, and the contractor did not return to correct these issues.
Plan Of Correction
Plan of Correction: Approved February 26, 2025 The sprinkler heads noted in the inspection to not be free of foreign materials were properly cleaned per life safety code standards. The sprinkler heads noted in the inspection to be corroded or rusted have been replaced per life safety code standards. The escutcheon noted in the inspection as missing has been replaced. The sprinkler piping and pipe hangers noted to have been exposed to external loads during inspection have had the loads removed. The quarterly inspection, testing and maintenance of the automatic sprinkler system noted as lacking has been verified and documented. The post indicator valve that was found during inspection to have been seized in the open position will be repaired to proper function. An audit of all of the facilities sprinkler heads will be completed to assure they are free of foreign materials, not corroded or rusted and have escutcheons to meet the life safety code standards. An audit of all ceiling areas containing sprinkler piping and pipe hangers will be completed to confirm they have not been exposed to external loads. There are not other post-indicator valves in the facility. The quarterly inspection, testing and maintenance of the automatic sprinkler system will be audited for completion to assure the facility remains compliant with timely quarterly inspections. Any and all areas found during these audits to be non-compliant will be cleaned, repaired or replaced to assure compliance with life safety code standards. A review of the facilities policy related to sprinkler system inspections will be completed to assure it contains language that outlines the requirements of quarterly sprinkler inspections, to include frequency, scope, documentation, individuals responsible and follow-up procedures on identified issues. All maintenance staff will receive education and in-servicing on this new policy and procedure. Random audits of sprinkler inspection documents, as well as inspection of sprinkler heads and sprinkler piping will be completed monthly, for three months to assure ongoing compliance. These audits will include checking for lint/dust on sprinkler heads, corrosion on sprinkler heads, proper escutcheon placement, checking sprinkler piping for external load, and visual inspection of the post indicator valve. These audit results will be placed on the agenda of the Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Director of Maintenance will be responsible for ongoing compliance with these corrective measures.