Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to comply with sprinkler system regulations as evidenced by observations and document reviews. During a survey, it was noted that the sprinkler heads in the kitchen dishwashing area were dust-covered, dirty, and corroded. Additionally, the documentation for the third quarter sprinkler system inspection was not available at the time of the survey. An interview with the maintenance supervisor confirmed these deficiencies, indicating a lapse in the maintenance and testing of the facility's sprinkler system.
Plan Of Correction
A. Kitchen Sprinkler Heads Dust-covered maintenance cleaned kitchen sprinkler heads identified. Maintenance completed audit of whole house sprinkler heads, cleaned the sprinkler heads of dust and changed escutcheons as needed. NHA/Designee to educate maintenance staff by 21MAR2025 on importance of dust free, corrosion free sprinkler heads/escutcheons. Maintenance to complete weekly x4 audits of kitchen sprinklers. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. B. 3rd Quarter Sprinkler Documentation Maintenance immediately completed sprinkler head audit. Maintenance will maintain documentation of inspections. NHA/Designee to educate maintenance staff by 21MAR2025 on the importance of completing sprinkler maintenance and maintaining inspection documentation. NHA/designee will complete quarterly x3 documentation audit to ensure sprinkler system maintenance documentation is complete. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the quarterly audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.