Failure to Complete Required Sprinkler System Inspections and Testing
Penalty
Summary
The facility failed to maintain compliance with required fire safety standards by not completing an annual fire sprinkler service within the past twelve months. During interviews and record reviews, facility staff, including the Administrator and Maintenance Supervisor, were unable to provide documentation of the most recent annual sprinkler system inspection and testing, as required by NFPA 25. This lapse was confirmed by the Regional Maintenance Director, who acknowledged the absence of the annual service record. Additionally, the facility did not conduct the mandatory 20-year test for quick-response sprinkler heads throughout the building. When requested, staff could not produce documentation of this test, and the Regional Maintenance Director confirmed that the 20-year quick response sprinkler service and test had not been completed. These deficiencies were identified through interviews and record reviews conducted by surveyors, with no mention of specific residents or their medical conditions in relation to the findings.
Plan Of Correction
Facility's Safety Committee will provide further recommendations as necessary. Completion Date: 3/28/2025. K353 Sprinkler System - Maintenance and Testing Correct Deficient Practice: On 3/07/25 MS Called Delta Fire to schedule Annual Fire Sprinkler Test on 3/07/25. On 3/14/25 Kord Fire Protection to schedule the facility's 20 Year Quick Release Sprinkler Test on 4/03/25. Identify Others: All residents, employees, and visitors are at risk due to this deficient practice. Systemic Changes: On 03/10/2025 Administrator provided in-service education to Maintenance Supervisor regarding facility policy and procedures titled, "Maintenance Services" & "Fire Safety Inspections," indicating the maintenance department is responsible for maintaining the fire alarm system in good working order and the need for Annual and 20 Year Quick Response Sprinkler Test inspections to be completed and forwarded to the administrator within 48 hours. Any negative findings will be reported to administrator and corrected immediately. Monitoring: Findings and trends from Inspection rounds will be brought to Quarterly Safety Committee meeting by MS until Safety Committee has determined compliance has been sustained. Facility's Safety Committee will provide further recommendations as necessary. Completion Date: 3/28/2025.