Failure to Maintain and Document Fire Sprinkler System Inspections
Penalty
Summary
The facility failed to maintain the automatic fire sprinkler system in accordance with regulatory requirements. During a document review and interview, surveyors found that the Auxiliary Drain information sign located on the west outside wall near the generator was faded and illegible. The Maintenance Director stated that the contractor responsible for replacing sprinkler system signs during the semi-annual inspection had been informed about the need for replacement approximately two months prior, but the sign had not yet been replaced. Additionally, the facility was unable to provide records of the required annual sprinkler system inspection and testing. The only documentation available was from a five-year sprinkler inspection/test conducted previously. The Maintenance Director indicated that the facility was under contract with a sprinkler company that was supposed to conduct annual inspections automatically, but no records for the most recent annual inspection could be located. This deficiency affected all staff and all 192 residents across six smoke compartments.
Plan Of Correction
K353 NFPA 101 Sprinkler System - Maintenance and Testing How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: The automatic fire sprinkler system inspection and testing was immediately scheduled and completed on 5/27/25. The auxiliary Drain Information sign was replaced on 5/27/25. No residents were affected by the finding. The automatic fire sprinkler system inspection and testing was immediately scheduled and completed on 5/27/25. The auxiliary Drain Information sign was replaced on 5/27/25. No residents were affected by the finding. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: All residents have the potential to have been affected by this finding. Maintenance director completed audit to ensure all inspections and testing are up to date. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: Maintenance staff were in serviced on 5/27/25 by the Administrator regarding policy on ensuring that all sprinkler inspections and testing are completed to ensure compliance. Maintenance director will ensure that all logs are reviewed monthly for the next 3 months. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: The Administrator or designee will review inspection and testing records for the next 3 months to monitor for compliance. Any issues will be reported to the Quality Assurance committee for review and recommendations. Completion date of corrective actions: June 9, 2025. K 353