Deficient Sprinkler System Maintenance and Missing Signage
Penalty
Summary
The facility failed to maintain its automatic sprinkler system in accordance with NFPA 25 and NFPA 13 standards. During a tour and document review, surveyors observed that two sprinklers located at the front entrance of the facility had accumulated dust and debris on their bodies and deflectors. Staff confirmed that these components were typically cleaned on a monthly basis. Additionally, the annual sprinkler system testing record indicated a failed test due to missing required signage for the control valves and the fire department connection (FDC) servicing the building. Further observations revealed that the FDC on the riser along the southwest side of the building was missing identification signage, and the control valve in the same area also lacked the necessary signage. Staff confirmed these findings and stated that the facility was in the process of obtaining new signs. These deficiencies affected all 92 residents and all six smoke compartments within the facility.
Plan Of Correction
K 353 - Sprinkler System Maintenance and Testing How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: • The facility has immediately removed dust and debris on the exterior sprinklers. • The required signage for the fire department connection and control valve were installed on 4/2/25 by the EVS Director. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: • All residents have the potential to be affected. • A full facility-wide sprinkler system inspection has been conducted to identify any additional deficiencies. No other deficiencies have been identified. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: • A monthly maintenance checklist will be completed by the EVS Director to ensure that all sprinkler system components are clean and free of debris. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: • A monthly maintenance checklist will be completed by the EVS Director to ensure that all sprinkler system components are clean and free of debris. • Results will be reviewed in the QAPI meetings for ongoing compliance oversight. Date of Compliance 4/18/25