Deficient Sprinkler System Maintenance and Testing
Penalty
Summary
The facility failed to maintain and test its automatic sprinkler and standpipe systems in accordance with NFPA 25 requirements. Observations on multiple occasions revealed several deficiencies, including ceiling tile penetrations in the IT/Telecom Room and storage room, missing ceiling tiles in the Maintenance Office and laundry area, and missing or incomplete sprinkler components such as escutcheon rings and concealed covers in various rooms including a resident bathroom, Dietary Rest Room, Dialysis Treatment Room, and Conference Room. Additionally, dirty sprinkler heads were found behind the dryers in the laundry, and stock items were stored within 18 inches of a sprinkler head in the vestibule for dialysis storage. These issues were confirmed by the Maintenance Director during the survey. Further review of facility records showed a lack of documentation for the required quarterly flow tests for the automatic fire suppression system for two consecutive quarters. No evidence of these tests was provided to the surveyor by the time of exit. The combination of physical deficiencies and missing compliance documentation affected all 175 residents in the facility, as confirmed through interviews and record reviews with the Maintenance Director.
Plan Of Correction
K353 - Sprinkler System Maintenance and Testing 1. The facility failed to provide sprinkler system maintenance and testing as required by NFPA 25. a. The ceiling tile penetration on 2nd floor new side by IT/Telecom room has been replaced. b. The ceiling penetration in 2nd floor storage room with roof access has been replaced. c. Escutcheon plate in the 2nd floor room #235 has been replaced. d. The ceiling tile penetration in Maintenance Office by the IT equipment rack has been replaced. e. Dirty sprinkler heads behind the dryers have been cleaned. f. Missing sprinkler head in the Dietary restroom has been replaced. g. Escutcheon plate in the Dialysis den has been replaced. h. Missing sprinkler in the 1st floor conference room has been replaced. i. All combustibles and stock items within 18" have been removed from dialysis storage room. j. Missing ceiling tile above the washers in the laundry room has been replaced. 2. The maintenance director and staff will be educated on the importance of routine rounding to ensure the sprinkler heads have escutcheon plates and are clean, ceiling tiles maintain no breaches, and combustible/stock items maintain 18" from the ceiling. 3. To ensure continued compliance, the Maintenance director/designee will complete random audits 5 times a week for 4 weeks. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.