Deficiencies in Sprinkler System Maintenance and Structural Integrity
Penalty
Summary
The facility failed to maintain its automatic sprinkler system properly, as evidenced by the absence of a quarterly inspection for the third quarter of 2024. The Maintenance Director acknowledged that the inspection was overlooked and only realized the omission after the fourth quarter had begun. The vendor confirmed that the third quarter inspection was skipped, highlighting a lapse in the facility's maintenance schedule, which is crucial for ensuring the safety of residents and staff. Additionally, the facility did not address a failed backflow prevention device in the basement, which was identified during an annual test on February 8, 2024. The Maintenance Director was unaware of the failure and confirmed that no repairs had been made. Furthermore, the facility had structural deficiencies, including a missing ceiling tile in the A-Unit janitor's closet and holes in the main kitchen ceiling. These issues were not reported through work orders, and the Maintenance Director was unaware of them, indicating a lack of communication and oversight in maintaining the facility's infrastructure.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 Sprinkler system inspections are up to date in 2025. The backflow devices were inspected and repaired on 2/5/2025. A third backflow is now decommissioned. Missing ceiling tile was replaced. Going forward, the Director of Environmental Services will have calendar reminders on when quarterly inspections are due and ensure they are completed timely. A new vendor has been selected to inspect and repair backflows immediately if necessary. Ceiling tile visual inspections will be added to the daily tour logs to ensure no tiles are damaged or missing. All Maintenance staff have been educated on the importance of complying with quarterly sprinkler inspections. The Director of Facilities also educated staff on why it is important to review inspection reports prior to signing report repairs. The Director of Environmental Services will monitor compliance with audits that track scheduled quarterly sprinkler inspections, backflow inspections, and ceiling tile visual inspections with a 100% threshold, and report the results to the Quality Assurance Committee quarterly.