Sprinkler Heads Not Maintained Free of Debris in Main Kitchen
Penalty
Summary
Surveyors observed that the facility failed to maintain sprinkler heads in the Main Kitchen area, as they were found to be covered with debris throughout, particularly by all vents and sprinkler heads. This deficiency was identified during an inspection and was confirmed through interviews with the Administrator and Director of Environmental Services, who acknowledged the presence of debris on the sprinkler heads. The issue affected one of nine smoke zones within the component and was documented based on direct observation and staff confirmation. No information regarding residents' medical history or condition at the time of the deficiency was provided in the report.
Plan Of Correction
The facilities maintenance department audited the entire facility for other dirty/debris covered sprinkler heads. The affected sprinkler heads will be cleaned. Checking for dirty/debris on the sprinkler heads will be added to the monthly safety committee checklist. Checklists will be analyzed to identify/track trends or patterns and will be reported to the facility Quality Assurance/Performance Improvement Committee for review and/or recommendation.