Sprinkler System Maintenance Deficiency
Penalty
Summary
The automatic sprinkler system in the main kitchen of the facility was not maintained according to the National Fire Protection Association (NFPA) 13 Standard for the Installation of Sprinkler Systems 2010 Edition. Specifically, observations revealed that boxes were stored within 18 inches of the bottom of sprinkler deflectors in the kitchen walk-in refrigerator and walk-in freezer. Additionally, three sprinkler heads in the laundry dryer area were found to be coated with dust or lint. These deficiencies were identified during observations conducted on two separate occasions, indicating a failure to adhere to fire safety regulations as required by the NFPA standards.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 What corrective action will be accomplished for those residents found to have been affected by the deficient practice? 1) The items on the top storage of the main kitchen were removed on 12/17/24. The three sprinkler heads in the laundry dryer area were cleaned on 12/17/24. Education was provided to all dietary staff relative to appropriate storage areas by Regional Dietician on 12/17/2024. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? 2) All residents and staff have the ability to be affected by this deficient practice. The maintenance director or designees audited storage areas to ensure nothing is stored within 18 inches of the bottom of the sprinkler. No additional areas were identified. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur? 3) Weekly audits of storage in the kitchen to be conducted by Food Service Director or maintenance director weekly times 4 weeks and monthly times 2 months. The laundry room sprinkler heads have been placed on the monthly preventive maintenance schedule for routine cleaning. The food service director and maintenance director were educated on storing items at below 18 inches from sprinkler deflector. The maintenance director was educated on keeping all sprinklers free from dust and lint. How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction? 4) Findings of the weekly audits and monthly preventative maintenance of sprinkler heads will be reviewed by the Quality Assurance Performance Improvement Committee monthly for 3 months and additional recommendations for interventions and duration of audits will be given as needed. Responsible Parties: Administrator, Dietician, Food Service Director and Director of Maintenance.