Failure to Document Quarterly Sprinkler System Testing
Penalty
Summary
The facility failed to maintain and test its automatic sprinkler system in accordance with Life Safety Code (LSC) Sections 19.7.6, 4.6.12, 9.7.5, and NFPA 25. During a review of facility records, it was found that there was no documentation available for the required quarterly testing of the sprinkler system for the fourth quarter of 2024. This lack of documentation was confirmed during an interview with the Maintenance Director at the time of the records review. No information was provided regarding any specific patients or their medical conditions in relation to this deficiency.
Plan Of Correction
K353 Sprinkler System- Maintenance and Testing Element 1 No residents were harmed due to this deficient practice. All residents and staff have the potential to be affected by this deficient practice. Element 2 Testing of the sprinkler system took place on Jan 29, 2025, and April 15, 2025. Element 3 Education was provided to the Maintenance Director regarding scheduling and monitoring to ensure the Quarterly testing of the sprinkler system occurs timely, and documentation of the test is available for review. Element 4 The Quarterly Sprinkler System Test schedule and documentation will be audited monthly by the Maintenance Director to ensure it is scheduled and performed timely and that the documentation of the inspection is available for review. The Quarterly Sprinkler System Test schedule and documentation of the test findings will be presented to and reviewed by the QAPI Committee monthly until such time that consistent substantial compliance has been achieved and maintained as determined by the committee. The Maintenance Director will be responsible for sustained compliance.