Failure to Maintain Automatic Sprinkler System
Penalty
Summary
The facility failed to maintain the automatic sprinkler system in compliance with NFPA 25 standards, as evidenced by several deficiencies observed during a survey. On the first floor, a penetration in the ceiling assembly was noted in the Activities Closet, which could compromise the integrity of the fire protection system. Additionally, sprinkler head assemblies in the Laundry area were found to be 'loaded' with lint, indicating a lack of regular cleaning and maintenance. Furthermore, the facility did not have the required automatic sprinkler system testing and inspection data for the second quarter of 2024, nor did it have current data for the three-year full flow trip test inspection and testing. These deficiencies were confirmed during an exit interview with the Facility Administrator and the Facilities Manager.
Plan Of Correction
This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because The Williamsport Home agrees with the allegations and citations listed on the statement of deficiencies. The Williamsport Home maintains that the alleged deficiencies do not, individually, and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as The Williamsport Home's written credible allegation of compliance. By submitting this plan of correction, The Williamsport Home does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and The Williamsport Home reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding. 1. a) The unsealed penetration will be sealed in Activities closet by February 26, 2025. b) The sprinkler head assemblies in the laundry area were cleaned on February 24, 2025. c) The facility cannot reactively correct the sprinkler testing for the second quarter of 2024. d) The facility cannot reactively correct the three-year full flow trip test inspection and data. 2. a) A full house audit will be conducted by the Maintenance Director or designee for any penetrations observed by February 28, 2025. Any penetrations identified will be sealed per Life Safety guidelines. b) A full house audit will be conducted by the Maintenance Director or designee for to ensure sprinkler heads are clear of any lint by February 28, 2025. Any areas identified will be cleaned. c) A quarterly schedule will be developed for 2025 to ensure quarterly sprinkler testing is completed. d) The three-year full flow trip test inspection will be scheduled by the end of the first quarter of 2025. 3. The Nursing Home Administrator or designee will conduct training/education with maintenance personnel regarding the requirement of K032 to include monitoring for penetrations, lint free sprinkler heads, quarterly sprinkler testing and three-year trip testing and data by March 7, 2025. 4. a) An audit on penetrations and linen covered sprinkler heads will be conducted weekly x 2 and then monthly x 2 by the Maintenance Director or designee. The results of the audit will be taken to monthly QA by the Maintenance Director for review. b) Maintenance Director or designee will complete an audit for any quarterly sprinkler testing quarterly x4. The results of the audit will be taken to monthly QA by the Maintenance Director for review. c) Maintenance Director or designee will complete an audit annually for the completion of the full flow-trip. The results of the audit will be taken to monthly QA by the Maintenance Director for review.