Sprinkler System Maintenance Deficiency Identified
Penalty
Summary
During an inspection, it was observed that the sprinkler head located near the dishwashing room on the third floor had an excessive gap around the escutcheon. This issue was identified on July 30, 2025, at 11:00 a.m. The deficiency was confirmed in an interview with the Facility Administrator and Maintenance Director later that day. The report specifies that this failure to maintain the automatic sprinkler system affected one of seven smoke compartments in the facility. No information regarding residents or their medical conditions was included in the report, and the deficiency is limited to the maintenance and physical condition of the fire protection system.
Plan Of Correction
On July 30, 2025, the Maintenance Director repaired the excessive gap around the escutcheon. The Nursing Home Administrator re-educated the Maintenance Director and maintenance assistant on the need to ensure no excessive gaps are present around the sprinkler heads. The Maintenance Director conducted a whole house audit to ensure no other sprinkler heads had an excessive gap. The Maintenance Director or designee will conduct a sprinkler head monthly audit. The audit findings will be submitted to the Safety Committee for review.