Sprinkler System Maintenance Deficiency
Summary
The automatic sprinkler system in Building #31 (House #1) was not maintained according to the National Fire Protection Association (NFPA) 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 2011 Edition. Specifically, the top of storage was found to be less than 18 inches from the sprinkler deflectors, which is a violation of sections 4.1.6.1 and 5.3.1.1.1.6 of the NFPA 25 standard. This deficiency was observed during a recertification survey on March 28, 2025, at 2:24 PM, in both the storeroom and walk-in freezer. During an interview conducted shortly after the observation, the Facilities Manager acknowledged the issue and indicated plans to address the storage placement and communicate with the dietary department regarding the storage requirements.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 Element 1: Storeroom and walk-in freezer was moved to ensure storage is not within 18 inches of the sprinkler. Element 2: All kitchen storage areas will be checked to ensure storage meets requirements with sprinkler clearance. Any inconsistency in storage will be corrected at time of identification and education provided. Element 3: The nurse educator or designee will provide education to food service staff regarding storage clearance requirements. This education will be part of onboarding of new staff and annual education. Element 4: Weekly audits of the storage room and walk-in freezer will be completed to ensure that storage is not within 18 inches of sprinkler. Audits will continue for 3 months. Results of audits will be reviewed at the monthly Quality Assurance Committee meeting. Audits will continue for 3 months; at that time, the Quality Assurance Committee will make recommendations regarding ongoing audits, frequency, or change in plan. Facility manager responsible for ongoing compliance.
Penalty
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.