Failure to Maintain Sprinkler System Integrity and Function
Penalty
Summary
The facility failed to maintain the sprinkler system as required, as evidenced by observations on three of four floors. On the 3rd and 2nd floors, there were open areas in the walls behind beds in two resident rooms, each measuring approximately 12 inches by 2 inches, which could cause a delay in sprinkler activation. Additionally, on the 1st floor, a sprinkler located over a bed in one room was found to be covered in paint overspray. These deficiencies were confirmed during an exit conference with facility leadership, including the Administrator, Regional Director, Regional Maintenance Director, and Environmental Services Director. No information about the medical history or condition of residents in the affected rooms was provided in the report.
Plan Of Correction
The facility failed to maintain the sprinkler system on three of four floors. No residents were affected. All residents have the potential to be affected. The open area in the wall behind the A bed in room 315 on the 3rd floor was repaired. The open area in the wall behind the B bed in room 204 on the 2nd floor was repaired. The sprinkler over the B bed in room 102 on the 1st floor was repaired and paint was removed. A facility-wide audit was completed to ensure that there are no other open areas in walls. An audit of the facility's remaining sprinklers was completed by the Director of Maintenance to assure that they meet the requirement. The Director of Maintenance and maintenance staff were educated by the Administrator on the requirement to maintain the sprinkler system according to the regulation. They were also educated on sprinkler head inspection to ensure that they meet the requirement. The Maintenance Director/Designee will conduct one random weekly audit to ensure that there are no open areas in walls for four weeks, then monthly for two months and quarterly thereafter. They will also conduct one random weekly audit of all sprinklers for four weeks, then monthly for two months and then quarterly thereafter. Results of audits will be reviewed at the Quarterly Quality Assurance and Improvement Committee Meeting over the duration of the audit process. Based on the results of the audits, a decision will be made regarding the need for continued submission and reporting.