Improper External Loading on Fire Sprinkler Piping
Penalty
Summary
During a facility inspection, surveyors conducted an above-ceiling inspection in the corridor outside of the Dietary Department. They observed that external wiring was loaded onto the fire sprinkler piping, which is not compliant with NFPA 101 and NFPA 25 standards for the maintenance and testing of automatic fire sprinkler systems. The Assistant Director of Maintenance, who was present during the inspection, confirmed that he was not aware of the issue prior to the surveyors' findings. The deficiency was acknowledged and confirmed by both the Administrator and the Assistant Director of Maintenance during the exit conference. The report includes photographic evidence of the deficiency. No information regarding specific residents or their medical conditions was provided in relation to this deficiency.
Plan Of Correction
A) What corrective action will be accomplished for these residents found to be effective: All residents have the potential to be affected by this deficient practice; however, a specific individual was not identified in this deficiency. On 4/28/25, the external loading of wiring on the fire sprinkler piping noted above the ceiling in the corridor outside the Dietary Department was corrected. On 4/28/25, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director of the need to conduct inspections above the ceiling to ensure that there is no wiring touching or around the automatic fire sprinkler system and is maintained in compliance with the regulations (NFPA Code 101). B) How will you identify other residents having potential to be affected and what corrective actions will be taken: All residents have the potential to be affected by this practice. On 4/28/25, the external loading of wiring on the fire sprinkler piping noted above the ceiling in the corridor outside the Dietary Department was corrected. On 4/28/25, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director of the need to conduct inspections above the ceiling to ensure that there is no wiring touching or wrapped around the automatic fire sprinkler system and is maintained in compliance with the regulations (NFPA Code 101). On 4/28/25, the Maintenance Director and Assistant Maintenance Director completed an inspection of the wiring for the fire sprinkler in the area above the ceiling. Any concerns were addressed. C) What measures will be put in place or what system change will be made to ensure this will not recur: On 4/28/25, the external loading of wiring on the fire sprinkler piping noted above the ceiling in the corridor outside the Dietary Department was corrected. On 4/28/25, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director of the need to conduct inspections above the ceiling to ensure that there is no wiring touching or wrapped around the automatic fire sprinkler system and is maintained in compliance with the regulations (NFPA Code 101). On 4/28/25, the Maintenance Director and Assistant Maintenance Director completed an inspection of the wiring for the fire sprinkler in the area above the ceiling. Any concerns were addressed. The Administrator Consultant developed a tracking schedule for the completion of inspections of the wiring for the fire sprinkler in the area above the ceiling. On 4/28/25, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director on the tracking schedule. The schedule notes the dates on which the Maintenance Director is to complete inspections of the wiring for the fire sprinkler in the area above the ceiling. The Maintenance Director is to provide documentation to the Administrator of the date of the inspections. Upon completion of the inspections, the Maintenance Director is to provide a copy of the report to the Administrator. D) How the corrective action will be monitored to ensure the potential will not occur: The Maintenance Director, or designee, will report the findings of the inspections to the QA and QAPI committee monthly x 12 months.