Sprinkler System Deficiency Due to Missing Escutcheons
Penalty
Summary
The facility failed to maintain the hardware components of its automatic sprinkler protection system, affecting one of seven smoke compartments. During an observation on January 7, 2025, at 11:15 AM, it was noted that the sprinkler head closest to the corridor door in the Care South Country Kitchen was missing an escutcheon. This deficiency was confirmed through an interview with the Administrator at the same time. Additionally, another observation at 11:33 AM on the same day revealed that the sprinkler head located in the corridor outside Resident Room C-148 was also missing an escutcheon, which was again confirmed by the Administrator.
Plan Of Correction
The enclosed plan of correction set forth in these documents does not constitute admission or agreement by the provider of the truth of the facts alleged or concluded set forth in the statement of deficiencies. The plan of correction is prepared and or executed solely because it is required by the provision of Federal and State law. 1. What systematic changes will be put in place to ensure that the deficiency does not recur, and how the corrective action(s) will be monitored. The sprinkler head escutcheon was placed onto the sprinkler heads located closest to the corridor door, within the Care South Country Kitchen and in the corridor outside Resident Room C-148 on 1.7.2025. Maintenance Director completed a full inspection and did not identify any further sprinkler/escutcheon concerns. Education was provided on 1.7.25 - 1.17.25 by NHA and Maintenance Director on the proper maintenance and importance of the sprinkler system specifically the escutcheons being intact at all times. 2. What quality assurance program will be put into place, and the dates when corrective actions will be complete. Action plan #455 was initiated. Audits will be done monthly X3 then quarterly by the Maintenance Director. The Maintenance Director will then report the findings to the QA Committee quarterly to ensure compliance with this regulation. The corrective action will be completed by 2.7.25.