Sprinkler System Not Maintained Free of Extraneous Weight
Penalty
Summary
Surveyors determined that the facility failed to maintain the automatic sprinkler system free of extraneous weight in three of twelve smoke compartments. During observations conducted above the ceiling in multiple areas, including the 2nd floor above the Nurses' Station, the North Hall by a resident room, and the 3rd floor above the Nurses' Station, various items such as multiple wires and flex conduit were found laying across or attached to the sprinkler piping system and its brackets. These findings were confirmed during an interview with the Administrator and Director of Maintenance, who acknowledged the presence of these items attached to and supported by the sprinkler pipe system. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
Remove existing wiring (various items) from sprinkler piping, in the locations noted, and install separate hanging devices as needed using an above ceiling permit program. Education of the requirements will be provided to the appropriate staff. Audits of above ceiling work will be conducted, monthly x3. Findings will be reviewed in monthly QAPI meetings.