Sprinkler System Installation Noncompliance Due to Ceiling Modification
Penalty
Summary
During an unannounced Fire & Life Safety recertification survey, it was observed that the facility failed to maintain their sprinkler system installation in accordance with NFPA 101 and NFPA 13 standards. Specifically, in Electrical Room #5, the drop ceiling had been removed, resulting in two sprinkler heads being positioned too far below the new ceiling level. This alteration led to inadequate coverage by the sprinkler system in that room, as the sprinkler heads were no longer properly aligned with the ceiling as required by code. The deficiency was identified during a facility tour conducted with the Maintenance Director, who confirmed the findings during an interview. The issue was reviewed with both the Administrator and the Maintenance Director at the exit conference, and photographic evidence was obtained to document the noncompliance. No information regarding residents or their medical conditions was included in the report, and the deficiency was limited to the physical plant and fire safety systems.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement of the provider of the truth of the alleged or conclusion set forth in the CMS measured star ratings. The plan of correction is prepared and executed solely because it is required by Federal and State Laws. K351 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. No residents were affected by this alleged deficient practice. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: 2. The facility will maintain the supervised automatic fire sprinkler system in accordance with NFPA 101. Electrical Room #5 is scheduled to be corrected on 4/15/25 to ensure adequate coverage of the automatic fire sprinkler system protection in accordance with NFPA 101. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: 3. Maintenance staff re-educated on ensuring inspection of every compartment for sprinkler system. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put in place: 4. Maintenance Director or Designee will report the findings of the automatic fire sprinkler audits to the QAA&C monthly times three months or until substantial compliance is met.