Failure to Maintain and Test Sprinkler System per NFPA 25
Penalty
Summary
The facility failed to comply with NFPA 25 requirements for the inspection, testing, and maintenance of its automatic sprinkler system. Specifically, records showed that the 2nd, 3rd, and 4th quarter sprinkler flow tests were not conducted or documented, as no test results were available at the time of the survey. Additionally, an observation in the therapy room revealed a sprinkler head dated 1967, indicating it had not been replaced or updated in over 50 years. These deficiencies were confirmed through record review and interview with the Facility Maintenance Director.
Plan Of Correction
K353 1. The Maintenance Director and/or designee will conduct a sprinkler flow test and replace the sprinkler head in the Therapy room. 2. The Administrator will review regulation K353 and provide education to the Maintenance team on the requirements. 3. The Maintenance Director and/or designee will ensure sprinkler system maintenance is scheduled for the remainder of 2025. The Maintenance Director and/or designee will ensure the Preventative Maintenance system flags for sprinkler system maintenance to ensure compliance. Results of sprinkler system testing will be brought to the Quality Assurance Performance Improvement meeting monthly for review. 4. The Administrator is responsible to attain and maintain compliance. Completion date for compliance will be 06.20.25.