Failure to Perform Required Sprinkler System Inspections and Maintenance
Penalty
Summary
The facility failed to maintain its automatic sprinkler system in accordance with NFPA 25 requirements. Specifically, the facility did not perform monthly inspections of the sprinkler system components, such as gauges and valves. During the survey, it was found that 8 out of 12 required records documenting these monthly inspections were not provided. The Plant Operations Manager confirmed during an interview that only quarterly visual inspections were being conducted, rather than the required monthly inspections. This deficiency had been previously cited during a prior Life Safety Code Recertification Survey. Additionally, a corroded sprinkler head was observed in Dining Room C of the main building. The Director of Subacute stated during the interview that they were unaware of the corroded sprinkler head. The presence of corrosion on the sprinkler head is a direct violation of NFPA 25, which requires that sprinkler heads be free from corrosion, leakage, and other physical damage. These failures affected all 59 residents in the facility, as well as all four smoke compartments. The lack of proper inspection and maintenance of the sprinkler system and its components, as well as the presence of a corroded sprinkler head, were identified through observation, record review, and staff interviews during the survey.
Plan Of Correction
The sprinkler located by dining room C was replaced by contracted company. (Please see the attachment.) Scheduled recurring preventative maintenance was implemented to occur monthly to visually inspect the sprinklers PM schedule. MONITORING: 1. The plant operations team, headed by the Plant Operations Director or qualified designee, will be inspecting the sprinklers on a semi-annual basis. 2. Added monitoring is a visual inspection to be conducted during Environment of Care (EOC) rounding on a quarterly basis. Action plans are generated with findings and deadlines for completion. Findings and data trends are reported to the environment of care committee on a quarterly basis for further review and recommendations. K 353