Deficiencies in Fire Sprinkler System Maintenance
Penalty
Summary
The facility failed to maintain its Automatic Fire Sprinkler System (AFSS) in accordance with NFPA 101 standards. During an inspection on April 30, 2025, it was discovered that the annual AFSS inspection conducted on February 17, 2025, identified deficiencies, specifically that the water flow was not reporting to the fire panel. No documentation was provided to show that this deficiency had been repaired. This issue was acknowledged by the Director of Plant Operations during the review. Further observations during the fire safety tour revealed multiple issues with the sprinkler system. At the Reflections Nurses Station, a white wire was found laying on top of the AFSS piping. In the Reflections Television Cable Room, a fire sprinkler head was loaded with paint on the deflector. The Kitchen had two out of three loaded dry sprinkler heads in the walk-in coolers, and the Beauty Supply Room had one of two loaded fire sprinkler heads. Additionally, the Phone Room in the Laundry corridor had a sprinkler surrounded by a ceiling with open seams, exposing the interstitial space above. Additional deficiencies included a red tag in the Fire Riser Room indicating the water flow issue, an illegible hydraulic design calculation sign, and a missing spare concealed sprinkler wrench. Insulation was found on top of the sprinkler piping near Room 206 in the Seaway Wing. The Physical Therapy Riser Room's spare sprinkler head box lacked a list of spare fire sprinkler heads, and the Independent Wing Riser Room had an illegible hydraulic design sign. These findings were acknowledged by the Director of Plant Operations and explained to the Administrator during the exit conference.
Plan Of Correction
No residents were affected by this alleged deficient practice as of 05/16/2025 and none can be identified as of 05/16/2025. The maintenance director and assistants were educated by the Executive Director on 05/16/2025 on K353. 1. Above the ceiling of the Reflections Nurses Station, the wire was removed on 05/16/2025 by the maintenance director/designee. 2. Dynafire was notified to replace the Reflections Television Cable Room had 1 of 1 loaded fire sprinkler heads on 05/16/2025 by the maintenance director/designee. 3. Kitchen 2 of 3 loaded dry sprinkler heads in the walk-in coolers were cleaned on 05/15/2025 by the maintenance director/designee. 4. Dynafire was notified to replace the Beauty Supply Room loaded sprinkler head on 05/16/2025 by the maintenance director/designee. 5. The Phone Room, in the Laundry corridor will have the ceiling repaired by 05/24/2025 by the maintenance director/designee. 6. The Fire Riser Room, in the Laundry corridor, was inspected by Dynafire before 05/24/2025 and the red tag was removed by Dynafire. The sprinkler wrench was ordered from Dynafire on 05/15/2025. The hydraulic sign will have a repair estimate by 05/24/25 to make the sign legible. 7. The Seaway Wing, near Room 206, had the insulation removed from on top of the sprinkler pipe by the maintenance director/designee. 8. The Physical Therapy Riser Room spare sprinkler head box had a list of all of the required items posted on the wall next to the box at the time of survey. The list is posted as it does not fit inside the box. 9. The Independent Wing Riser Room hydraulic sign was inspected by Dynafire, and the center has contacted the original manufacturer Brown, on 05/13/25. The original data is unable to be retrieved. Dynafire is unable to update the data as of 05/13/25. The center will have the repair estimates to replace the signage by 05/24/25 for the Independence and Laundry corridor signs. This was completed by the maintenance director/designee. Sprinkler heads, ceilings surrounding sprinkler heads, fire riser rooms, and sprinkler piping and hydraulic signs will be audited weekly x4 weeks and monthly x6 months for compliance with K353 by the maintenance director/designee. The results of these audits and any necessary repairs will be brought to QAPI for review. No residents were affected by this alleged deficient practice as of 05/16/2025 and none can be identified as of 05/16/2025. The maintenance director and assistants were educated by the Executive Director on 05/16/2025 on K353. 1. Above the ceiling of the Reflections Nurses Station, the wire was removed on 05/16/2025 by the maintenance director/designee. 2. Dynafire was notified to replace the Reflections Television Cable Room had 1 of 1 loaded fire sprinkler heads on 05/16/2025 by the maintenance director/designee. 3. Kitchen 2 of 3 loaded dry sprinkler heads in the walk-in coolers were cleaned on 05/15/2025 by the maintenance director/designee. 4. Dynafire was notified to replace the Beauty Supply Room loaded sprinkler head on 05/16/2025 by the maintenance director/designee. 5. The Phone Room, in the Laundry corridor will have the ceiling repaired by 05/24/2025 by the maintenance director/designee. 6. The Fire Riser Room, in the Laundry corridor, was inspected by Dynafire before 05/24/2025 and the red tag was removed by Dynafire. The sprinkler wrench was ordered from Dynafire on 05/15/2025. The hydraulic sign will have a repair estimate by 05/24/25 to make the sign legible. 7. The Seaway Wing, near Room 206, had the insulation removed from on top of the sprinkler pipe by the maintenance director/designee. 8. The Physical Therapy Riser Room spare sprinkler head box had a list of all of the required items posted on the wall next to the box at the time of survey. The list is posted as it does not fit inside the box. 9. The Independent Wing Riser Room hydraulic sign was inspected by Dynafire, and the center has contacted the original manufacturer Brown, on 05/13/25. The original data is unable to be retrieved. Dynafire is unable to update the data as of 05/13/25. The center will have the repair estimates to replace the signage by 05/24/25 for the Independence and Laundry corridor signs. This was completed by the maintenance director/designee. Sprinkler heads, ceilings surrounding sprinkler heads, fire riser rooms, and sprinkler piping and hydraulic signs will be audited weekly x4 weeks and monthly x6 months for compliance with K353 by the maintenance director/designee. The results of these audits and any necessary repairs will be brought to QAPI for review.