Failure to Maintain and Document Sprinkler System Inspections and Maintenance
Penalty
Summary
The facility failed to provide documentation verifying that quarterly inspections of both wet and dry automatic sprinkler systems were conducted for the second and third quarters of 2024. During document review, it was found that records confirming these inspections were missing, and this was confirmed by the Administrator and Maintenance Director. Additionally, two sprinkler heads located behind the dryers in the laundry area were found to be incorrectly oriented above the ceiling tile, an issue previously identified in a quarterly report but not corrected. The facility also lacked documentation showing that deficiencies related to the wet system's Supervisory Flow Switches and Tamper Flow Switches, which failed to register as a priority on the fire alarm panel, had been resolved. Further observations revealed that multiple sprinkler heads in the laundry room were covered with debris, specifically four in the clean area, two in the soiled area, and two in the personal area. These findings were confirmed by the Administrator and Maintenance Director during the exit conference. The report does not mention any residents or specific patient involvement, nor does it provide information about their medical history or condition at the time of the deficiency.
Plan Of Correction
1. The facility will ensure the wet/dry sprinkler systems are subject to inspection and/or testing at least quarterly. The two sprinkler heads noted during the survey behind the dryers in Laundry will be modified for correct orientation. The 1 and 2 Wet System Supervisory Flow Switches will be repaired to resolve the issue. The sprinkler head identified as covered with debris will be cleaned. The sprinkler inspection reports will be maintained in the facility Life Safety book, including repair reports. 2. The Maintenance Director or designee will perform at least quarterly audits of the facility Life Safety book to confirm that the sprinkler system has been inspected and tested, and that deficiencies have been repaired. Audit results will be reported to the QAPI Committee. Date of compliance is 7/30/2025.