Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its automatic sprinkler system in accordance with NFPA 25 standards, as evidenced by multiple sprinkler deflectors throughout the building that were found with dust buildup, paint, and a green mildew-like substance. During a series of observations and interviews, surveyors identified these deficiencies in several locations, including the kitchen dry goods storeroom, social service storeroom, administrator's office, CNA storeroom, resident rooms, and the shower room. In each instance, the maintenance supervisor acknowledged the presence of dust, paint, or mildew on the sprinkler deflectors. A review of the facility's maintenance policy indicated that the maintenance department is responsible for ensuring the building and equipment are kept in a safe and operable condition at all times, including compliance with federal, state, and local regulations. Despite this policy, the observed conditions showed that the sprinkler system components were not being properly maintained, as required by NFPA 25, which mandates that sprinklers be free of corrosion, foreign materials, paint, and physical damage, and be installed in the correct orientation.
Plan Of Correction
BEL VISTA HEALTHCARE CENTER makes every effort to operate in substantial compliance with Federal and State laws and regulations. Nothing in this Plan of Correction is an admission otherwise. BEL VISTA HEALTHCARE CENTER is submitting this Plan of Correction in compliance with its regulatory obligations and does not waive any objections it may have as to the merit or form of any allegations contained herein. Please note that the facility may contest the merits or form of any of the alleged deficient findings and may take reasonable steps to appeal them. This Plan of Correction constitutes BEL VISTA HEALTHCARE CENTER's written credible allegation of compliance for the deficiencies noted. It is the facility's policy to comply with all applicable federal and state regulations regarding NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, specifically section 5.2.1.1.1 concerning sprinkler maintenance and testing. Corrective Action Taken: On 05/19/2025, the Maintenance Director initiated immediate cleaning and restoration of all affected sprinkler heads. A licensed fire protection contractor was engaged to properly clean and inspect all sprinkler deflectors throughout the facility, with special attention to those identified in the survey findings. All painted sprinkler heads were replaced with new, properly rated sprinkler heads. The shower room sprinkler head showing mildew was replaced and the surrounding ceiling area was treated for mold prevention. Identification of Other Areas with Potential to be Affected: On 05/20/2025, the Maintenance Director and Fire Safety Officer conducted a comprehensive facility-wide inspection of all sprinkler heads and deflectors in all smoke compartments. This inspection documented the condition of each sprinkler component and identified any additional heads requiring cleaning or replacement. Systemic Changes and Measures Implemented: 1. A new monthly sprinkler inspection checklist has been implemented that specifically addresses cleanliness, paint, corrosion, and proper orientation of all sprinkler heads. 2. The preventive maintenance schedule has been updated to include quarterly deep cleaning of all sprinkler heads by qualified maintenance staff. Monitoring and Quality Assurance: The Maintenance Director will conduct weekly inspections of randomly selected sprinkler heads throughout the facility for the next 90 days. The Director of Maintenance will oversee all monitoring activities and report findings to the quarterly Quality Assurance and Performance Improvement (QAPI) committee. The QAPI committee will monitor compliance until substantial compliance is achieved and maintained for three consecutive quarters. Date of Completion: 06/12/2025