Failure to Maintain Documentation of Quarterly Sprinkler System Inspections
Penalty
Summary
The facility failed to provide documentation verifying that quarterly inspections of the automatic sprinkler system were conducted over the previous twelve months. During a document review, it was found that there was no documentation available to confirm that the sprinkler system was inspected between January 23, 2025, and July 3, 2025. This was confirmed in an interview with the Director of Maintenance, who acknowledged the absence of inspection records for the specified period. The deficiency affected the entire sprinkler system component, as required records of inspection and maintenance were not available for review.
Plan Of Correction
Quarterly sprinkler inspections were conducted at Laureldale Skilled Nursing and Rehabilitation Center throughout the previous 12 months. Maintenance staff will be educated on ensuring all sprinkler inspection documentation is maintained moving forward. Maintenance Director/Designee to perform quarterly audits on sprinkler inspection documentation for 1 year to ensure compliance. Results of audits will be forwarded to the QAPI Committee.