Sprinkler System Maintenance Deficiencies
Summary
The facility failed to maintain the automatic sprinkler system in six instances, affecting four of twenty-seven smoke compartments. On December 16, 2024, observations revealed deficiencies such as insulation supported by the sprinkler line in the 6300 attic and gaps greater than 1/8 inch in rooms #5328, #4116, and #4118. On December 17, 2024, further deficiencies were observed, including a gap greater than 1/8 inch in the track of the ceiling tile outside room 4321 and flexible insulated ductwork laying on a sprinkler line above the double doors next to room 4172. Interviews with the Unit Director of TCU, Facility Staff, and the Safety Manager confirmed these deficiencies.
Plan Of Correction
The insulation will be relocated off of the sprinkler pipe in the 6300 attic. The ceiling tile will be replaced in rooms 5328, 4116, 4118, and 4321. The insulated ductwork will be relocated off of the sprinkler pipe in room 4172. All of these resolutions will be reported to the hospital safety committee and included in the hospital quality assurance program. All sprinkler lines are monitored and will continue to be monitored annually as part of the "Annual Fire and Smoke barrier above the ceiling program." Ceiling tiles are monitored and will continue to be monitored during hazard surveillance rounds by a multi-disciplinary team including representatives from safety, infection control, facilities, and environmental services.
Penalty
Surveyors found that the facility failed to maintain required documentation for its fire sprinkler system. During review and interview, the facility could not provide records of semi-annual inspections for valve supervisory switches or annual inspections for control valves. The maintenance supervisor confirmed that these sprinkler system inspection records were not available when requested by surveyors.
Surveyors found that the facility failed to maintain required documentation for multiple fire protection system tests and inspections, including the annual fire hydrant flow test, the five-year GPM test of the hydrant, the five-year internal inspection of the fire riser, and the five-year hydrostatic test of the FDC, as required by NFPA 101 and NFPA 25. In addition, the facility lacked records of required fire drills for each shift per quarter, with missing drills for one quarter’s third shift and for the second and third shifts of the last quarter of the prior year. The Maintenance Director acknowledged that these records were not available.
Surveyors determined that the facility did not maintain required documentation for its automatic sprinkler system. Record review showed the sprinkler system was past due for the mandated 5-year internal inspection, and the facility could not produce the most recent 5-year inspection report. During interview, the Maintenance Director confirmed that this inspection report was missing, and the deficiency was cited as affecting the entire facility.
Surveyors found that required sprinkler system inspection documentation was incomplete, with only three quarterly reports available and the 2nd quarter annual sprinkler report missing. During observation of the exterior car port, one of six sprinkler heads was obstructed by underside aluminum paneling. The Administrator and Maintenance Director confirmed both the missing documentation and the obstruction.
Surveyors identified that the facility did not maintain its automatic sprinkler system in accordance with NFPA standards when electrical MC wire conduit was found resting directly on sprinkler piping above ceiling tiles in the elevator lobby areas on two separate floors, affecting two of fifteen smoke compartments. The Facility Administrator and Director of Maintenance acknowledged these sprinkler system deficiencies during interview.
Surveyors identified that the facility failed to maintain required inspection and testing of its automatic sprinkler system in accordance with NFPA standards. Record review showed only one documented sprinkler inspection within the prior year, and no additional inspection records were produced despite multiple requests during the survey. The Maintenance Director confirmed that no other sprinkler inspection documentation was available, indicating that ongoing required inspections were not documented for all residents in the facility.
Missing Documentation for Required Sprinkler System Inspections
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain required documentation for its automatic sprinkler system. During document review and interview on April 30, 2026, at 10:50 a.m., the facility was unable to provide records showing that semi-annual inspections of valve supervisory switches had been completed, as required. At the same time, the facility also could not produce documentation of annual inspections for the sprinkler system control valves. The maintenance supervisor confirmed during the interview that the sprinkler system documentation for these required inspections was unavailable at the time of the survey. No residents or specific patient conditions were mentioned in the report, and the deficiency centered solely on missing inspection and maintenance records for the fire sprinkler system components.
Plan Of Correction
Completion Date: 05/29/2026 Status: APPROVED Date: 05/20/2026 Maintenance department was educated on the need for the sprinkler system to be inspected and tested at regular intervals that includes semi annual for valve supervisory switches and annual control valves. The semi annual inspection will be scheduled to be completed per NFPA-0100 25. The annual control valve inspection will be scheduled to be completed per NFPA-0100 25. Random audits will be completed by the Administrator and/or designee monthly for 6 months to assure that semi annual valve supervisory switched and annual control valve testing was completed. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine compliance or need for continuation of audits.
Failure to Maintain Sprinkler System Testing and Fire Drill Documentation
Penalty
Summary
Surveyors identified deficiencies related to the facility’s failure to maintain and test its automatic sprinkler and associated fire protection systems in accordance with NFPA 101 and NFPA 25. During record review between 9:15 AM and 1:30 PM with the Maintenance Director, the facility was unable to provide documentation that an annual flow test had been performed on the on-site fire hydrant as required. The Maintenance Director acknowledged that the facility failed to provide documentation that this annual hydrant flow test was completed. Further record review during the same time period showed that the facility also lacked documentation of the required five-year gallons-per-minute (GPM) testing of the fire hydrant. In addition, the facility could not produce records showing that a five-year internal inspection of the fire riser had been performed. The Maintenance Director acknowledged the absence of documentation for the five-year internal riser inspection. Surveyors also found that the facility failed to provide documentation that a five-year hydrostatic test of the Fire Department Connection (FDC) had been completed. Separately, the surveyors reviewed fire drill records and determined that the facility did not have documentation of required fire drills for each shift per quarter. Specifically, fire drills were missing for the third shift of the first quarter of one year and for the second and third shifts of the last quarter of the prior year. The Maintenance Director acknowledged that the facility failed to provide documentation that these fire drills were performed.
Plan Of Correction
The five year gallon per minute testing was completed on [R] The five year internal inspection was performed on the riser on [R] The five year hydrostatic testing was performed and completed on [R] The five year gallon per minute testing on the fire hydrant was completed on [R] The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct for a period of three months a random audit of completed documentation. The five year gallon per minute testing was completed on [R] The five year internal inspection was performed on the riser on [R] The five year hydrostatic testing was performed and completed on [R] The five year gallon per minute testing on the fire hydrant was completed on [R] The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct for a period of three months a random audit of completed documentation.
Missing 5-Year Internal Sprinkler System Inspection Report
Penalty
Summary
Surveyors found that the facility failed to maintain proper inspection documentation for its automatic sprinkler system in accordance with NFPA 25. During record review at 10:50 AM, the most recent sprinkler system report showed that the facility was past due for the required 5-year internal inspection. The facility was unable to provide the most recent 5-year internal inspection report for review. During a concurrent staff interview, the Maintenance Director acknowledged that the 5-year internal inspection report was missing. This deficiency was determined to affect the entire facility’s sprinkler system coverage. No residents or specific patient conditions were mentioned in the report, and no additional clinical details were provided.
Plan Of Correction
This Plan of Correction constitutes written compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet requirements established by State and Federal Law. To comply with K0353 and assure continued compliance, the following plan has been put in place: K0353 - Sprinkler System Testing (5-Year Internal) Immediate Correction: A licensed fire sprinkler vendor was to perform the 5-year internal piping inspection per NFPA 25 to ensure the system is free of obstructions. Identification of Others: All fire protection systems were audited. The internal pipe inspection report is now maintained in the Life Safety binder for immediate surveyor review. Systemic Changes: A Master Regulatory Calendar was implemented to track multi-year NFPA requirements. The service contract was updated to require the vendor to provide 90-day advance notice of all upcoming 3-year and 5-year tests. Monitoring (QA): The Maintenance Supervisor will audit the Master Calendar monthly. Results will be reported to the QAPI Committee quarterly.
Incomplete Sprinkler Inspection Records and Obstructed Exterior Sprinkler Head
Penalty
Summary
Surveyors identified a deficiency in the facility’s compliance with NFPA 25 requirements for inspection, testing, and maintenance of the automatic sprinkler system. During document review, only three quarterly sprinkler inspection reports were available for the following time frames: 4th quarter dated 3/10/26, 3rd quarter dated 11/5/25, and 1st quarter dated 5/15/25, and the 2nd quarter annual sprinkler report was not available for review. In addition, during observation of the exterior car port area, one of six sprinkler heads was found to be obstructed by underside aluminum paneling. At the exit interview, the Administrator and Maintenance Director confirmed both the missing sprinkler system documentation and the obstructed exterior sprinkler head. No residents or specific patient conditions were mentioned in the report, and the deficiency focused solely on the facility’s failure to maintain complete sprinkler system inspection records and to ensure unobstructed sprinkler head coverage in the exterior car port.
Plan Of Correction
The Maintenance Director has hired a qualified vendor to facilitate quarterly sprinkler tests and will be conducted during the following months: August 2026, November 2026, and February 2027 to ensure compliance. The Maintenance Director has hired a qualified vendor to repair the sprinkler head within the exterior car port which was obstructed by aluminum paneling. Quarterly sprinkler head maintenance and the exterior sprinkler head repair will be monitored by the Maintenance Director and/or designee and presented to the Quality Council monthly to ensure compliance.
Improper Support of Sprinkler Piping by Electrical Conduit in Two Smoke Compartments
Penalty
Summary
Surveyors found that the facility failed to properly maintain its automatic sprinkler system in accordance with NFPA 25 and NFPA 101 requirements. During observations on April 27, 2026, an electrical MC wire conduit was seen resting directly on sprinkler piping above the ceiling tiles in the elevator 4 lobby on the 3 East unit at 9:15 a.m. A similar condition was observed at 9:35 a.m. above the ceiling tiles in the elevator 4 lobby on the 2 East unit, where another electrical MC wire conduit was resting on sprinkler lines. These deficiencies affected two of fifteen smoke compartments. In an interview on April 28, 2026, at 1 p.m., the Facility Administrator and Director of Maintenance confirmed the identified automatic sprinkler system deficiencies. No residents or specific patient conditions were mentioned in the report, and the deficiency pertains solely to the physical environment and maintenance of the sprinkler system components in the identified areas.
Plan Of Correction
1. On April 27, 2026, the electrical MC wire conduit resting on the sprinkler piping above the ceiling tiles in the Elevator 4 Lobby on 3 East was removed and Elevator 4 Lobby on 2 East was removed and properly supported to eliminate contact with the sprinkler system piping. The Director of Maintenance verified that no damage occurred to the sprinkler piping or system 2. The Director of Maintenance conducted a facility-wide inspection above accessible ceiling spaces to identify any additional instances of electrical conduit, wiring, or other materials resting on sprinkler piping. Any additional findings identified during the inspection were immediately corrected at the time of discovery. 3. The Director of Maintenance educated maintenance department on requirements prohibiting any item from being supported by or resting on sprinkler piping. 4. The Director of Maintenance or designee will conduct weekly inspections x4 weeks and then monthly after, of a minimum of five random above-ceiling locations throughout the facility to verify compliance. Findings will be documented and reviewed during the facility's (QAPI) meetings monthly for three months
Failure to Maintain Required Sprinkler System Inspection Documentation
Penalty
Summary
The facility failed to properly maintain its automatic sprinkler system in accordance with NFPA 101 (2012) and NFPA 25 (2010), affecting all 67 residents in the building. During record review on 03/25/26 beginning at 8:45 A.M., surveyors found only one documented sprinkler inspection within the previous 12 months, dated 04/23/25. Additional documentation of required inspections was requested at the entrance conference at 8:40 A.M., and again at 9:35 A.M. and 10:10 A.M., but no further records were provided by the time of exit. An interview with the Maintenance Director confirmed that there were no other sprinkler inspection records available, verifying the lack of documented ongoing inspection and maintenance of the sprinkler system. No specific resident medical histories or conditions at the time of the deficiency were described in the report.
Plan Of Correction
1.Based on record review, observation and interview, no residents experienced negative outcomes related to sprinkler system deficiencies. The facility failed to ensure sprinkler system inspection, testing, and maintenance were completed and documented in accordance with NFPA 25. Findings included lack of complete inspection documentation within the required timeframe and identified physical deficiencies (including missing escutcheon plates). 2.The Medical Director was notified by LNHA on 03/26/2026 that the facility failed to ensure sprinkler system inspections, testing, and maintenance were completed and documented in accordance with NFPA 101 and NFPA 25 requirements. 3.Sprinkler system inspection, testing, and maintenance will be completed by a contracted fire protection vendor on or before 04/30/2026. This will include implementation of a full Inspection, Testing, and Maintenance (ITM) program in accordance with NFPA 25 (2010 Edition), including but not limited to: Completion of a full annual sprinkler system inspection in accordance with NFPA 25 §13.6.2.1. Quarterly testing of waterflow alarm devices and supervisory signals. Monthly and/or weekly inspection of control valves, gauges, and system condition as applicable. Five-year internal pipe inspection (obstruction investigation) if due. Inspection of all sprinkler heads to ensure no damage, corrosion, paint, loading, obstruction, or missing escutcheon plates. Verification that all components are installed correctly and maintained in reliable operating condition. All identified physical deficiencies (including missing escutcheon plates and any additional deficiencies discovered during inspection) will be corrected on or before 04/30/2026. A comprehensive facility-wide sprinkler system inspection will be completed to ensure no additional deficiencies exist. All inspection, testing, and maintenance activities will be placed on an automatically recurring schedule by Administrator/designee to ensure ongoing compliance. 4.Documentation of all sprinkler system inspection, testing, and maintenance activities will be maintained onsite and readily available at the time of survey. The Maintenance Director/designee will conduct routine audits to verify completion of required inspection, testing, and maintenance (ITM) activities. Compliance will be reviewed in QAPI every quarter and as needed to ensure ongoing systemic compliance. 5.LNHA educated Maintenance Director on 03/26/2026 regarding the requirements for maintaining the facility's fire suppression equipment, as well as ensuring required completion of backflow device testing; and required escutcheon plates to sprinkler heads.
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