Deficiency in Sprinkler System Coverage
Penalty
Summary
The facility failed to ensure that the building was fully protected by an approved automatic sprinkler system, as required by CMS regulation º 483.90(a) for multiple locations. Observations revealed mixed sprinkler coverage in the stairwells and boiler room, with both standard and quick response sprinklers present. Additionally, there was a lack of sprinkler coverage in an outdoor storage area under the building's roof, where two propane tanks and a gas grill were stored. During an interview, the Director of Facility Services acknowledged awareness of the regulation but was unaware of the mixed sprinklers and stated that the propane tanks would be relocated to a proper storage location.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 (Sprinkler System - Installation) The Facility Services Director is currently in the process of scheduling to have the incorrect sprinklers replaced in the following areas: - Stairwell on 2nd floor North East side by double doors that had one standard response head that should have been quick response. - The stairwell by kitchen that had one standard response head that should have been quick response. - 1st floor Boiler room/Mechanical room that had one standard response head that should have been quick response. (Two Propane tanks stored under exterior overhang): Both tanks have been removed. Missing spare sprinkler heads: The Facility Services Director is in the process of adding the following spare sprinkler heads: Green vertical spare heads, Blue pendant standard heads. The Facility Services Director or designee will conduct a facility-wide audit of all compartments with sprinklers. This will include auditing the exterior of the building and, in addition, the spare sprinklers cabinets. The Facility Services Director or designee on a quarterly basis will conduct a facility-wide audit of all compartments with sprinklers. This will include auditing the exterior of the building and, in addition, the spare sprinkler cabinets. Any deficiencies found will be corrected in a timely manner. The audits will be monitored and reported to the QAPI committee on a quarterly basis. The deficiency will be corrected no later than 3/25/25. The Facility Services Director will be responsible for this plan of correction.