Fire Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its automatic fire sprinkler system in accordance with NFPA 101 standards. During a facility tour, it was observed that a cable related to the facility's satellite system was improperly zip-tied to the fire sprinkler piping located on the exterior of the building. This improper attachment was connected to the fire riser piping, which is a violation of the maintenance standards for fire protection systems. Additionally, a sprinkler located in the medical records storage room was found to contain foreign material, further indicating a lack of proper maintenance and inspection. These deficiencies were identified during an inspection conducted by the Maintenance Director and the Regional Maintenance Consultant. The findings were acknowledged by both the Maintenance Director and the Regional Maintenance Consultant during the inspection and were subsequently reviewed with the Administrator during the exit conference. Photographic evidence was obtained to document these deficiencies, which were found to be in violation of the NFPA 101 and NFPA 25 standards for the inspection, testing, and maintenance of water-based fire protection systems.
Plan Of Correction
1. The Maintenance Director removed the zip tie from the cable related to the facility's satellite system on 4/9/2025. The sprinkler in the medical records storage room was serviced and cleaned by Maintenance staff on 04/2/2025. 2. The Maintenance Director conducted a quality assurance check on sprinkler heads on 4/18/2025. 3. Education was provided to the Maintenance Director by NHA on 4/17/2025 regarding maintaining the automatic fire sprinkler system in accordance with NFPA 101. Ongoing monthly quality assurance checks will be completed by the Maintenance Director or designee on facility sprinkler heads as a part of the facility preventive maintenance program. 4. All results of the quality assurance checks will be monitored and reviewed by the QA&A committee monthly to ensure continued compliance.