Sprinkler System Maintenance and Testing Deficiencies
Penalty
Summary
The facility failed to maintain its automatic sprinkler system in accordance with NFPA 25 and NFPA 13 standards. During a tour and interviews with staff, surveyors observed that inspector test valves (ITVs) in the medicine room by nurses station 3 and in the courtyard were missing required signage. Staff interviewed were unaware of the missing signs. Additionally, a sprinkler located in the storage closet next to nurses station 3 was found to be covered in dust, and staff were not aware of this condition. Further, when the waterflow was tested at the ITV in the medicine room by nurses station 3, it took 116 seconds for the alarm to initiate after the valve was fully opened, which exceeds the acceptable time for waterflow alarm activation. Staff interviewed were unaware of the reason for this delay. These deficiencies affected all 103 residents in the facility across five smoke compartments.
Plan Of Correction
K 353: How will the corrective action be accomplished for those residents found to have been affected by the deficient practice? The facility has not identified any residents affected by the deficient practice but recognizes that all residents have the potential to be affected. The facility contracted with MS Fire, a qualified contractor, to inspect each identified area of deficiency, and to determine and obtain the necessary signage for each Inspector Test Valve and all Auxiliary Drain valves. During this inspection, the valve located in the medicine room by station 3 was properly identified as an Auxiliary Drain Valve and not an Inspector Test Valve. Signage indicating that this is an Auxiliary Drain valve was placed during the inspection done on 04/02/2025. As this was identified as an Auxiliary Drain valve and not an Inspector Test Valve, MS Fire has corroborated during their inspection that the water flow expected of this valve was in working order and it is not expected to perform as an Inspector Test Valve, alarming in no more than 90 seconds. This is because Auxiliary Drain valves do not have the restricted head on the discharge pipe to correctly stimulate a fire sprinkler activation as an Inspector Test Valve would, and therefore this is why it took longer than 90 seconds to alarm. During this same inspection, the valve located in the courtyard was properly identified as an Auxiliary Drain Valve and not an Inspector Test Valve. Signage indicating that this is an Auxiliary Drain Valve was placed during the inspection done on 04/02/2025. Two other correctly identified Inspector Test Valves were tested during the survey process and performed within regulatory requirements, alarming in less than 90 seconds. The sprinkler located in the storage closet next to Nurses Station 3 was cleaned of dust on 3/26/25 by the Maintenance Lead and reinspected by MS Fire on 04/02/2025. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility recognizes that while no residents were identified to have been affected by the deficient practice, all residents have the potential to be affected. The same corrective actions as listed above are the corrective actions taken to eliminate the potential risk to the residents. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur? The Maintenance Director in-serviced all maintenance personnel on the locations and appropriate signage required for Inspector Test Valves and Auxiliary Drain valves. Also included in this same in-service was the importance of inspecting and cleaning sprinkler heads to keep them free of dust. The facility utilizes TELS Building Management System for all Maintenance related inspections or tasks. A monthly in-house fire sprinkler inspection task was added to the Maintenance TELS system to include checking fire sprinkler heads for dust and Auxiliary Drain Valves and Inspector Test Valves for appropriate signage. Any findings will be immediately corrected and reported by the Maintenance team member completing the task to the Maintenance Lead and/or Director. Housekeeping staff was in-serviced by the Hospitality Director/Environmental Services Director on how to clean fire sprinkler heads to keep them free of dust. How does the facility plan to monitor its performance to make sure that the corrective actions are implemented and achieved, the solutions are sustained, and that the corrective actions taken are evaluated for effectiveness through integrations into the facility's Quality Assurance system? The Facility Maintenance Director shall review monthly in-house sprinkler inspection task reports for completion and findings. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur? The Maintenance Director in-serviced all maintenance personnel on the locations and appropriate signage required for Inspector Test Valves and Auxiliary Drain valves. Also included in this same in-service was the importance of inspecting and cleaning sprinkler heads to keep them free of dust. The facility utilizes TELS Building Management System for all Maintenance related inspections or tasks. A monthly in-house fire sprinkler inspection task was added to the Maintenance TELS system to include checking fire sprinkler heads for dust and Auxiliary Drain Valves and Inspector Test Valves for appropriate signage. Any findings will be immediately corrected and reported by the Maintenance team member completing the task to the Maintenance Lead and/or Director. Housekeeping staff was in-serviced by the Hospitality Director/Environmental Services Director on how to clean fire sprinkler heads to keep them free of dust.