Sprinkler Heads Covered with Debris
Penalty
Summary
The facility failed to maintain the sprinkler heads in one of four smoke zones, as evidenced by an observation on December 3, 2024. During the inspection at 11:23 AM, it was noted that three sprinkler heads located outside on the Kitchen Loading Dock were covered with debris. This deficiency was confirmed during an interview at the exit conference with the Director of Nursing and Director of Maintenance on the same day at 1:30 PM, where it was acknowledged that the sprinkler heads were subject to load.
Plan Of Correction
Sprinkler heads will be cleared of debris. This occurred on 12/12/24. The sprinkler heads will be inspected by the Director of Environmental Services or designee every month as part of our preventative maintenance program. Audits will be completed by the Director of Environmental Services or designee weekly for every quarter to ensure compliance, and the results will be reported to the Quality Assurance and Performance Improvement Committee.