Sprinkler System Maintenance and Testing Deficiencies
Penalty
Summary
The facility failed to provide proper maintenance and testing of its automatic sprinkler system as required by NFPA 25. During an inspection, surveyors observed multiple instances of dirty sprinkler heads in various locations, including the Med "C" Nurse Storage Room, Eagle Room, Med "C" Dining Room, Employee Lounge, and Room 107. Additionally, a sprinkler head was found missing an escutcheon ring in the Housekeeping Managers Office, and three sprinkler heads in the corridor by the 1st floor elevator were recessed into the ceiling tile up to the deflector. There were also observations of missing ceiling tiles and a ceiling tile with a large annular space at a light fixture, which could compromise the effectiveness of the sprinkler system. Further deficiencies included combustible stock stored within 18 inches of sprinkler heads in the Business/Activities Office storage cage and the kitchen pantry, which violates clearance requirements for sprinkler systems. These findings were confirmed through interviews with the facility Maintenance Director and the Corporate Operations Director at the time of observation. The report does not mention any specific residents affected or their medical conditions at the time of the deficiency.
Plan Of Correction
K 353 Element # 1 The sprinkler heads in the Med C Nurse Storage Room, Eagle Room, Med C Dining Room, Employee Lounge and Room 107 were cleaned. The combustible stock on the Business/Activities Storage Cage and in the Kitchen Pantry was removed to be 18 inches from the ceiling and sprinkler heads. The missing ceiling tile in the Janitor Room was replaced. The escutcheon ring on the sprinkler in the Housekeeping Manager's office was replaced. The ceiling tile in the Housekeeping Manager's Office was replaced. The 3 recessed sprinkler heads in the corridor by the 1st floor elevator have been properly installed. Element # 2 Current residents have the potential to be affected by the deficient practice. All sprinkler heads were evaluated to ensure cleanliness and proper installation. Any sprinklers found to be out of compliance will be corrected. All ceiling tiles were evaluated for compliance. Any ceiling tiles that were out of compliance are to be replaced. Element # 3 The maintenance department was re-educated on sprinkler head cleanliness, proper installation of sprinkler heads and missing/broken ceiling tiles. Element # 4 The Administrator and/or designee will conduct random audits of the sprinkler heads and ceiling tiles once a week for 1 month, then weekly for 1 month, and then monthly for 3 months to ensure substantial compliance. Results of the audits will be brought to the QAPI committee. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025