Failure to Maintain Fire Sprinkler System
Summary
The facility failed to maintain their automatic fire sprinkler system (AFSS) in accordance with NFPA 101 standards. During a record review conducted with the Maintenance Director, it was found that the facility did not provide the 5-year internal inspection report of the backflow device, which is a requirement under NFPA 25. No previous inspection report was available for review. This deficiency was acknowledged by both the Executive Director and the Maintenance Director during an interview and was further discussed during the exit conference.
Penalty
Surveyors found that the facility failed to perform and/or document the required 20-year testing of quick-response sprinkler heads throughout all smoke compartments, as required by NFPA 25. During review of Life Safety records with the Director of Environmental Services, no documentation of a 20-year sprinkler test was available, despite the sprinklers being original to the building. Spare sprinkler heads in stock showed manufacturing dates from the late 1990s, and the outside testing company could not provide historical records to confirm that the mandated 20-year testing had ever been completed.
Surveyors found that the Main Lobby had mixed sprinkler coverage, with two quick response and two standard sprinklers, which does not comply with NFPA requirements. The Regional Maintenance Director acknowledged the issue during the inspection, and the deficiency was documented with photographic evidence.
The facility did not provide documentation for required sprinkler system inspections and allowed sprinkler heads to become covered in dust and corrosion. Staff confirmed missing inspection records and overdue maintenance, and the facility was unable to complete necessary repairs due to a payment hold with the vendor. The deficiencies remained uncorrected during follow-up surveys, resulting in a continuous fire watch.
Surveyors found that sprinkler heads in the Main Kitchen were covered with debris, particularly around vents, and this was confirmed by facility leadership during interviews. The deficiency affected one of nine smoke zones.
Surveyors found that the facility failed to keep the automatic sprinkler system free of extraneous weight, with multiple wires and flex conduit observed attached to or laying across sprinkler piping in several areas above the ceiling. Facility leadership confirmed these items were present and supported by the sprinkler system.
Surveyors observed that the facility's automatic sprinkler system was not maintained free of extraneous weight, with multiple wires and flex conduit supported by sprinkler piping and brackets in two smoke compartments. Facility leadership confirmed these findings during the survey.
Failure to Perform and Document Required 20-Year Sprinkler Head Testing
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to conduct the required 20-year testing of quick-response sprinkler heads in accordance with NFPA 25. During an interview and record review with the Director of Environmental Services (DES), the facility’s Life Safety materials binder was found to lack any record of a 20-year sprinkler test for the quick-response sprinkler heads installed throughout all four smoke compartments. The DES reported that the sprinklers were original to the building, which was constructed in 1999, and stated that the required testing may have been done in 2009, but there was no documentation on site to verify that the test had occurred. Further observation and interview showed that spare quick-response sprinkler heads in the facility’s stock had manufacturing dates such as 1996 and 1999 printed on them, confirming the age of the system components. The DES indicated that the outside testing company was unable to locate records from that time period to confirm whether the 20-year sprinkler testing had been performed. As a result, there was no evidence available to demonstrate that the required 20-year sprinkler head testing had been completed for the sprinkler system serving all four smoke compartments, as required by NFPA 25 and related Life Safety Code provisions.
Plan Of Correction
K353 – Sprinkler System Maintenance and Testing (NFPA 25) How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. There were no residents identified as directly affected by this deficient practice. Upon identification on 3/12/2026, the facility immediately contacted a licensed fire protection vendor to schedule the required 20-year sprinkler head testing. The sprinkler system remains fully operational and monitored, ensuring continued fire protection coverage while corrective actions are implemented. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. On 3/13/2026, the Director of Environmental Services (DES) conducted a review of all available Life Safety documentation to confirm the absence of records for the 20-year sprinkler testing across all smoke compartments. The contracted licensed vendor has been engaged and performed testing on representative sprinkler heads throughout the facility in accordance with NFPA 25 standards on 3/19/2026. Response time, response time index and water seal release all passed. The report is dated 3/20/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. To prevent recurrence, the facility has implemented a Life Safety compliance tracking system that includes all required inspection, testing, and maintenance schedules in accordance with NFPA 25. On 3/13/2026, the DES re-educated staff on regulatory requirements for sprinkler system testing, including 20-year testing requirements for quick-response sprinkler heads. The facility will maintain all Life Safety documentation in a centralized, secure, and readily accessible binder and electronic file. Additionally, the facility will contract with a licensed fire protection vendor to ensure ongoing compliance with all inspection and testing requirements. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The DES or designee will track all required Life Safety inspections and testing through a compliance calendar and conduct monthly audits to ensure all required documentation is current and on file. Results of these audits will be reported to the Administrator and reviewed quarterly in the Quality Assurance and Performance Improvement (QAPI) committee meeting. Any identified gaps will be addressed immediately. The QAPI committee will monitor compliance until sustained. Include dates when corrective actions will be completed. The corrective action completion dates must be acceptable to the State Agency.
Deficiency in Sprinkler System Compliance
Penalty
Summary
The facility failed to maintain its automatic fire sprinkler system (AFSS) in accordance with NFPA 101 and related standards for one of twelve sampled smoke compartments. During a fire safety tour, surveyors observed that the Main Lobby contained mixed sprinkler coverage, with two of the four sprinklers being quick response and the other two being standard sprinklers. This observation was made in the presence of the Regional Maintenance Director, who acknowledged the findings at the time. The deficiency was identified through a combination of direct observation, record review, and staff interviews. The surveyors specifically noted the inconsistency in the type of sprinkler heads installed within the same area, which does not comply with the requirements set forth by NFPA 13 and NFPA 25. The issue was discussed with both the Administrator and the Regional Maintenance Director during the exit conference, and photographic evidence was obtained to document the condition. No information was provided in the report regarding any residents' medical history or their condition at the time of the deficiency. The deficiency was limited to the fire protection system in the Main Lobby smoke compartment, and the report did not mention any immediate consequences or incidents resulting from the mixed sprinkler coverage. The focus of the findings was on the facility's failure to ensure uniform and compliant sprinkler system installation and maintenance as required by applicable fire safety codes.
Plan Of Correction
Continued from page 4 By the same deficient practice: A facility-wide inspection of sprinkler heads was conducted by maintenance leadership to verify sprinkler type, response classification (quick response vs. standard response), and consistency within smoke compartments and common areas. Any future discrepancies identified will be corrected immediately. Measures to Prevent Recurrence: All future sprinkler repairs or replacements will require verification that sprinkler heads match the existing sprinkler type in the area. The Maintenance Director will review and approve all sprinkler work to ensure system consistency. The Maintenance Director was educated on applicable NFPA requirements related to sprinkler system consistency and sprinkler response type. Monitoring / Quality Assurance: Inspection and testing records will be maintained and reviewed annually through QAPI. Corrective Action for Affected Residents: The facility will correct the identified sprinkler system deficiency to ensure consistent and reliable fire protection within the affected smoke compartment. Specifically: The two (2) sprinkler heads in the Main Lobby that were identified as standard response sprinklers were scheduled for replacement. These sprinkler heads will be replaced with quick response sprinkler heads to ensure uniform sprinkler response characteristics throughout the area. Replacement will be completed by a licensed fire sprinkler contractor, and documentation will be maintained on-site. Identification of Other Residents Potentially Affected: To identify any additional areas that may be affected by the same deficient practice: A facility-wide inspection of sprinkler heads was conducted by maintenance leadership to verify sprinkler type, response classification (quick response vs. standard response), and consistency within smoke compartments and common areas. Any future discrepancies identified will be corrected immediately. Measures to Prevent Recurrence: All future sprinkler repairs or replacements will require verification that sprinkler heads match the existing sprinkler type in the area. The Maintenance Director will review and approve all sprinkler work to ensure system consistency. The Maintenance Director was educated on applicable NFPA requirements related to sprinkler system consistency and sprinkler response type. Monitoring / Quality Assurance: Inspection and testing records will be maintained and reviewed annually through QAPI. Will correct the identified sprinkler system deficiency to ensure consistent and reliable fire protection within the affected smoke compartment. Specifically: The two (2) sprinkler heads in the Main Lobby that were identified as standard response sprinklers were scheduled for replacement. These sprinkler heads will be replaced with quick response sprinkler heads to ensure uniform sprinkler response characteristics throughout the area. Replacement will be completed by a licensed fire sprinkler contractor, and documentation will be maintained on-site. Identification of Other Residents Potentially Affected: To identify any additional areas that may be affected by the same deficient practice: A facility-wide inspection of sprinkler heads was conducted by maintenance leadership to verify sprinkler type, response classification (quick response vs. standard response), and consistency within smoke compartments and common areas. Any future discrepancies identified will be corrected immediately. Measures to Prevent Recurrence: All future sprinkler repairs or replacements will require verification that sprinkler heads match the existing sprinkler type in the area. The Maintenance Director will review and approve all sprinkler work to ensure system consistency. The Maintenance Director was educated on applicable NFPA requirements related to sprinkler system consistency and sprinkler response type. Monitoring / Quality Assurance: Inspection and testing records will be maintained and reviewed annually through QAPI. By the same deficient practice: A facility-wide inspection of sprinkler heads was conducted by maintenance leadership to verify sprinkler type, response classification (quick response vs. standard response), and consistency within smoke compartments and common areas. Any future discrepancies identified will be corrected immediately. Measures to Prevent Recurrence: All future sprinkler repairs or replacements will require verification that sprinkler heads match the existing sprinkler type in the area. The Maintenance Director will review and approve all sprinkler work to ensure system consistency. The Maintenance Director was educated on applicable NFPA requirements related to sprinkler system consistency and sprinkler response type. Monitoring / Quality Assurance: Inspection and testing records will be maintained and reviewed annually through QAPI. Will correct the identified sprinkler system deficiency to ensure consistent and reliable fire protection within the affected smoke compartment. Specifically: The two (2) sprinkler heads in the Main Lobby that were identified as standard response sprinklers were scheduled for replacement. These sprinkler heads will be replaced with quick response sprinkler heads to ensure uniform sprinkler response characteristics throughout the area. Replacement will be completed by a licensed fire sprinkler contractor, and documentation will be maintained on-site. Identification of Other Residents Potentially Affected: To identify any additional areas that may be affected by the same deficient practice: A facility-wide inspection of sprinkler heads was conducted by maintenance leadership to verify sprinkler type, response classification (quick response vs. standard response), and consistency within smoke compartments and common areas. Any future discrepancies identified will be corrected immediately. Measures to Prevent Recurrence: All future sprinkler repairs or replacements will require verification that sprinkler heads match the existing sprinkler type in the area. The Maintenance Director will review and approve all sprinkler work to ensure system consistency. The Maintenance Director was educated on applicable NFPA requirements related to sprinkler system consistency and sprinkler response type. Monitoring / Quality Assurance: Inspection and testing records will be maintained and reviewed annually through QAPI.
Failure to Maintain and Document Sprinkler System Inspections and Maintenance
Penalty
Summary
The facility failed to meet sprinkler system requirements for two of three systems, as evidenced by missing documentation for required quarterly inspections and overdue trip tests. Specifically, there was no documentation for the second and third quarter sprinkler inspections, the last full-flow trip test was completed over three years prior, and the last annual partial trip test was completed more than a year ago. Additionally, a quarterly inspection noted that the system compressor had parts on order, and the facility was unable to provide further documentation due to a payment hold with the sprinkler vendor. Interviews with facility staff confirmed the lack of required documentation at the time of the survey. Further deficiencies were observed, including multiple sprinkler heads covered in dust and corrosion in the corridor outside the maintenance office and in the mechanical room inside the laboratory. These conditions were confirmed by staff interviews. During subsequent revisit surveys, it was found that the deficiencies had not been corrected, as the facility was still awaiting vendor approval and funding to schedule the necessary inspections and repairs. As a result, the facility was maintaining a continuous fire watch.
Plan Of Correction
1. Absolute Fire Protection will be contacted to ensure that: a. The fourth quarter sprinkler inspection is completed. b. The three-year, full-flow trip test is completed by April 30th, once the partial trip test verifies that the dry valves are working correctly. c. The annual partial trip test is completed by the designated "substantial compliance" date of 1/30/2026. d. Any needed parts for the system compressor are ordered, received, and installed to ensure the system compressor is operational. 2. The Administrator will assist the Environmental Services Director in ensuring that Absolute Fire Protection is contacted for service and that payment will be secured for any and all necessary parts to ensure the system compressor is operational. 3. The results of these corrective actions will be reviewed at the facility's next two quarterly Quality Assurance Performance Improvement meetings to ensure compliance. K 0353
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.
Sprinkler System Not Maintained Free of Extraneous Weight
Penalty
Summary
Surveyors determined that the facility failed to maintain the automatic sprinkler system free of extraneous weight in three of twelve smoke compartments. During observations conducted above the ceiling in multiple areas, including the 2nd floor above the Nurses' Station, the North Hall by a resident room, and the 3rd floor above the Nurses' Station, various items such as multiple wires and flex conduit were found laying across or attached to the sprinkler piping system and its brackets. These findings were confirmed during an interview with the Administrator and Director of Maintenance, who acknowledged the presence of these items attached to and supported by the sprinkler pipe system. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
Remove existing wiring (various items) from sprinkler piping, in the locations noted, and install separate hanging devices as needed using an above ceiling permit program. Education of the requirements will be provided to the appropriate staff. Audits of above ceiling work will be conducted, monthly x3. Findings will be reviewed in monthly QAPI meetings.
Sprinkler System Not Maintained Free of Extraneous Weight
Penalty
Summary
The facility failed to maintain its automatic sprinkler system free of extraneous weight, as required by NFPA 25 and related standards. During an observation on August 12, 2025, surveyors found that multiple wires and flex conduit were being supported by the sprinkler piping system above the ceiling near Resident Room 200 on the 2nd floor Engle. Additionally, on the 3rd floor Greenwood, above the ceiling by the elevator back of house, multiple wires were tied to a sprinkler bracket. These findings were confirmed during an interview with the Administrator, Vice President of Facilities, Life Safety Manager, and Facilities Manager.
Plan Of Correction
1) What systematic changes will be put into place to ensure that the deficiency does not recur, and how the corrective action(s) will be monitored; On 8/13/25, the Life Safety Manager contacted COR Construction (outside vendor) to schedule a walkthrough of required work to remove all extraneous weight on the automatic sprinkler system at the following locations: (a) 2nd floor Engle, above ceiling, by Resident Room 200, and (b) 3rd floor Greenwood, above ceiling, by elevator back of house. COR Construction will begin this work the week of September 1, 2025, with monitoring check-ins completed by the Life Safety Manager. 2) What quality assurance program will be put into place, and the dates when corrective action will be completed? COR Construction will inspect all sprinkler lines annually to ensure no extraneous weight affects the automatic sprinkler system in the Greenwood and Engle neighborhoods. Deficiencies will be identified and remedied at time of inspection. Results of the inspection and any identified deficiencies will be reported through the QAPI program. 3) Date of compliance: 9/30/25 THIS PAGE IS NOW PART OF THIS SURVEY
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