Failure to Maintain Fire Sprinkler System Free of Foreign Material
Penalty
Summary
The facility failed to maintain its automatic fire sprinkler system in accordance with NFPA 25 standards, as evidenced by the presence of foreign material on sprinkler heads. During a facility tour, surveyors observed a sprinkler head on the overhang of the Southwest Emergency Exit by Room 21 that was covered with spider webs and dirt. The Maintenance Director acknowledged that this sprinkler head had been ignored and may have been in that condition for some time. Additionally, a sprinkler head located in the closet of the Administrator Room was found to have paint covering it. The Maintenance Assistant stated that he had never paid attention to the closet sprinkler heads and that the condition may have persisted for a while. These deficiencies affected 18 of 43 residents in one of three smoke compartments and were identified through direct observation and staff interviews.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Sprinkler head located on the overhang of the Southwest Emergency Exit by Room 21 was thoroughly cleaned on 5/20/25. Fire sprinkler vendor was notified and on 6/2/25 the sprinkler head located in closet of administrative DSD office is scheduled to be replaced by vendor. 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 by this deficient practice. No residents were found to be affected by this deficient practice. What measures will be put into place or what systemic changes in the facility will make to ensure that the deficient practice does not recur: Administrator will audit the reports from the sprinkler system vendor to check for accuracy and completion. 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 by this deficient practice. No residents were found to be affected by this deficient practice. What measures will be put into place or what systemic changes in the facility will make to ensure that the deficient practice does not recur: Administrator will audit the reports from the sprinkler system vendor to check for accuracy and completion. 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. The Administrator shall report the outcome of the checks/inspections to the Quality Assurance and Assessment Committee (QA&A) during its monthly meeting. If determined that the facility has accomplished the objectives in the plan of correction as aforementioned and the results are successful, then the facility shall consider the matter resolved. The QA&A Committee shall continue to review until such time that the deficiency has been proven to be resolved for 3 consecutive months and/or as advised by the QA&A Committee. Date of Completion of Corrective Action: 06/02/2025