Failure to Maintain and Document Sprinkler System Inspections and Obstructions
Penalty
Summary
The facility failed to provide documentation verifying that quarterly sprinkler system inspections had been conducted within the previous twelve months. During a document review, no records were available to confirm that these required inspections had taken place, and this was acknowledged by the Administrator during an interview. Additionally, observations revealed that the sprinkler head in the walk-in freezer was obstructed by boxes, and a white wire in the basement Activities Room was being supported by the sprinkler system. Both issues were confirmed by the Administrator during interviews at the time of observation. These findings indicate that the facility did not maintain the sprinkler system in accordance with required standards, specifically regarding unobstructed sprinkler heads and ensuring the system was free from extraneous weight.
Plan Of Correction
1) A quarterly sprinkler system inspection was completed on 12/13/2024 and 4/25/2025. The obstructed sprinkler head in the walk-in freezer was cleared, and the wire supported by the sprinkler system in the basement Activities Room was removed. 2) The NHA reached out to SA Comunale to confirm the next quarterly sprinkler inspection was scheduled. The Maintenance Director will complete facility rounds to ensure sprinkler heads are free of obstruction, and that sprinkler pipes are free of obstruction. 3) The maintenance director was reeducated on quarterly sprinkler inspection requirements, on ensuring that sprinkler heads are free of obstruction, and that sprinkler pipes are not obstructed. 4) The NHA or designee will complete weekly rounds ×4 weeks then monthly ×2 months to ensure sprinkler heads and pipes are free of obstruction.