Deficiency in Fire Department Connection Signage
Summary
The facility failed to maintain proper signage for the Fire Department Connection associated with the installed sprinkler system. During an observation on February 12, 2025, at 12:55 PM, it was noted that the Fire Department Connection lacked identifying signage. This deficiency was confirmed during an interview with the Administrator and Maintenance Director at the exit conference on the same day at 1:30 PM.
Plan Of Correction
The maintenance director has installed a reflective sign identifying the location of the fire department hookup. The NHA and maintenance director will tour the facility and grounds to identify any other locations which may need additional or new signage to maintain compliance. The NHA and maintenance director will review life safety regulations for signage to ensure that the facility is in compliance. The maintenance director will audit the fire department connection sign with his generator checks to ensure the sign remains in place. Results of the audit will be forwarded to the QAPI committee for review.
Penalty
Surveyors identified that a room equipped with an FM-200 non-water-based fire protection system lacked the required warning sign indicating the presence of this extinguishing system. This deficiency affected one of the facility’s smoke compartments and was confirmed during an interview with the facility’s administrator and maintenance leadership.
Missing Warning Sign for FM-200 Fire Suppression System
Penalty
Summary
Surveyors found that the facility failed to maintain a non-water-based fire protection system in accordance with NFPA 99 (2012) 15.12.2. During an observation conducted at 11:40 a.m. on April 28, 2026, it was noted that a room equipped with an FM-200 extinguishing system did not have a required warning sign indicating the presence of this system. This omission was identified in one of 15 smoke compartments. In an interview held at 1:00 p.m. the same day, the Facility Administrator and Director of Maintenance confirmed the absence of the warning signage, thereby confirming the deficiency. No residents or specific patient conditions were mentioned in the report, and no additional contextual details beyond the missing warning sign for the FM-200 system and the staff confirmation of this issue were provided.
Plan Of Correction
1. On April 28, 2026, the required warning signage indicating the room was equipped with an FM-200 extinguishing system was installed at the entrance to the affected room. The Director of Maintenance verified the signage was properly posted and visible in accordance with applicable Life Safety Code and NFPA requirements. 2. On April 28, 2026, the Director of Maintenance conducted a facility-wide inspection of all rooms containing clean agent fire suppression systems, including FM-200 systems, to verify required warning signage was present. Any additional deficient areas identified during the inspection were corrected immediately. 3. Maintenance staff were re-educated regarding NFPA requirements for identification and warning signage associated with clean agent extinguishing systems. 4. The Director of Maintenance or designee will conduct monthly inspections for 3 months of all extinguishing system rooms to verify required signage remains in place and legible. Inspection findings will be documented and reviewed during the facility's (QAPI) meetings.
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