Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the sprinkler system in one location, specifically on one of the two floors. During an observation on April 21, 2025, at 11:19 am, it was noted that the Dietary walk-in freezer was missing an escutcheon. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Manager on the same day at 12:30 pm.
Plan Of Correction
1) Escutcheon in walk-in freezer was replaced. 2) To identify other areas for potential concern, Maintenance Director/ designee quality monitored sprinklers within facility for escutcheon plates. Negative findings addressed. 3) To prevent this from recurring, NHA/ designee re-educated Maintenance on sprinkler escutcheon plates. 4) To monitor and maintain compliance, Maintenance Director/ designee to quality monitor sprinkler escutcheon plates 1x weekly x 4 weeks then 2x monthly x 1 month. Findings will be forwarded to QA Committee for review and recommendation.