Deficiency in Sprinkler System Maintenance
Summary
The facility failed to maintain its sprinkler system in accordance with NFPA 25 standards, as evidenced by the lack of testing or replacement of sprinkler system gauges within the required five-year interval. During the Life Safety Code recertification survey, it was noted that the gauges had not been replaced or tested since December 23, 2019, which exceeded the five-year requirement. Additionally, the facility did not provide documentation of an antifreeze test for the sprinkler system, which is required annually to ensure the correct freeze point of the antifreeze solution. Further investigation revealed that the antifreeze test conducted on February 29, 2024, indicated an incorrect freeze point in the emergency stairwell system, with a recommendation to drain and replenish the system. However, there was no evidence provided to confirm that corrective actions were taken following this recommendation. The facility's failure to maintain proper records and perform necessary maintenance actions led to the deficiency noted in the survey.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 Pine (NAME) Center for Rehabilitation and Healthcare provides the following Plan of Correction: 1. No residents were affected by the deficient practice. 2. All residents have the potential to be affected by the deficient practice. 3. The facility has a signed quote for the gauge testing/replacement; the vendor will be onsite to perform the 5 year/gauge inspection/replacement. 4. The Administrator will coordinate with the EVS Director/vendor to conduct retesting of the emergency stairwell freeze point and drain and replenish if needed. 5. The vendor will be onsite 3/20/2025 to conduct all necessary testing/replacements. 6. The facility has created an alert in our maintenance portal to alert when the facility is due for testing. 7. The EVS Director/designee will coordinate with the vendor to schedule/conduct any further required testing. 8. The EVS Director/designee will call the vendor and have them come down to inspect the emergency stairwell system, and they will perform any necessary work and retest once the work is completed. 9. The EVS Director/designee will report any findings at the quarterly QA/QAPI meetings. 10. The EVS Director/designee are responsible to correct this deficiency.
Penalty
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