Deficiencies in Sprinkler System Maintenance and Documentation
Penalty
Summary
The facility failed to maintain proper documentation and maintenance of its sprinkler system, as evidenced by the absence of 5-year sprinkler gauge replacement/calibration and internal pipe and valve inspection records. During a review of documentation, it was confirmed that the facility lacked these critical maintenance records. Additionally, the facility did not address the failure of the annual main drain test due to low water pressure, which was identified on August 28, 2024. This failure was confirmed during an interview with the Administrator and Maintenance Director. Further observations revealed physical obstructions and debris affecting the sprinkler system. Multiple items, such as wires and flex conduits, were found laying across the sprinkler pipes in various locations throughout the facility. Additionally, several sprinkler heads in the Laundry Room were covered with debris, which could impede their functionality. These issues were confirmed during an exit conference with the facility's Administrator and Maintenance Director.
Plan Of Correction
The 5-year sprinkler inspection report was located with last inspection performed on June 30, 2021. Results posted in Life Safety Book. The failed main drain test performed on August 28, 2024 due to low water pressure will be followed up to make necessary repairs as recommended by a qualified sprinkler company. The sprinkler company will be at the facility on April 1, 2025 to provide the facility with a remedy and work will be scheduled as soon as possible thereafter. Items laying across sprinkler pipes in the following areas have been removed from the sprinkler pipes: 1st floor, above ceiling by Resident Room D15 1st floor, above ceiling by Resident Room C1 2nd floor, above ceiling by Physical Therapy 2nd floor, above ceiling by Resident Room F18 The Maintenance Director will spot check other areas above the ceiling throughout the facility on a monthly basis to check for items laying on sprinkler pipes. After any vendor work above the ceiling, the Maintenance Director or NHA will inspect the area before the vendor leaves the facility. The sprinkler heads in the laundry area have been cleaned and will be inspected monthly by the NHA or designee. The Maintenance Director was re-educated on the need to maintain documentation so that it is easily retrievable; to follow up with repairs to any failed inspections and to not have anything laying across sprinkler pipes. The Maintenance Director or designee will audit inspection reports for timeliness and follow up repairs weekly for four weeks and then monthly for 3 months and report the results to the facility's QAPI committee. The NHA or designee will audit inspection reports on a quarterly basis to make sure recommended repairs are completed and that all inspection reports are timely and filed in the Life Safety Book.