Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the sprinkler system in one location, specifically affecting one of two floors. During an observation on April 30, 2025, at 9:55 am, it was found that three sprinkler heads within the basement laundry area were loaded with lint. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager on the same day at 11:00 am.
Plan Of Correction
The 3 basement laundry sprinkler heads were thoroughly cleaned of lint. The Maintenance Director will conduct an audit of sprinkler heads within the basement laundry to verify that the sprinklers are lint free. The Nursing Home Administrator/designee will provide re-education to the Maintenance Director for the requirements for sprinkler heads being free from lint. The Maintenance Director/designee will conduct audits of random sprinkler heads to confirm that they are free of lint and verify compliance weekly audits x 4 weeks, then monthly x 2 months. The results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for compliance.