Incomplete Fire Watch Policy for Sprinkler System Outage
Summary
The facility failed to maintain compliance with fire safety regulations by not having a complete fire watch policy in place. During a record review and interview, it was found that the facility's fire watch policy did not specify that a fire watch would be implemented after no more than ten hours of the sprinkler system being out of service. Staff confirmed that the required time frame was not included in the policy. This deficiency affected all 90 residents across ten smoke compartments, as the policy omission could impact the facility's response during a sprinkler system impairment.
Plan Of Correction
The facility recognizes the importance of maintaining the Sprinkler System. The facility shall continue to maintain the Sprinkler System. When the Sprinkler System is out of service, the facility shall update the Fire Watch policy to include language indicating "fire watch will be implemented after no more than ten hours of the sprinkler system being out of service." The updated Fire Watch policy will be reviewed, updated, and approved June 26, 2025 during the QA Committee meeting. Further issues regarding the Fire Watch policy or the sprinkler system shall be received during the QA process and brought to the QAPI Committee for review and discussion. The Administrator, Environmental Services Supervisor, QA Manager, maintenance staff, and nursing staff shall be responsible for monitoring and ongoing compliance.
Penalty
A dry sprinkler system was found out of service because of a malfunctioning air compressor, with the backup unit also inoperable and not connected to power. No documentation was available regarding the duration or extent of the outage, and the deficiency remained uncorrected as repairs had not been completed. The facility maintained a continuous fire watch during this period.
A review of facility documentation and staff interviews revealed the absence of a fire watch policy for periods when the sprinkler system is impaired or out of service for more than ten hours. This deficiency was confirmed by the DON and Director of Maintenance.
The facility did not implement a fire watch or post required signage when the sprinkler system was out of service, and staff including a CNA and the ADON were unaware of the outage, as revealed by inspection and interviews.
Sprinkler System Out of Service Due to Equipment Failure
Penalty
Summary
A deficiency was identified when the facility failed to maintain compliance with sprinkler system regulations for one of its two dry sprinkler systems. On observation, system #1 was found to be out of service due to a malfunctioning air compressor, and the backup air compressor was not operational or connected to a power source. There was no documentation provided regarding the extent or duration of the system being out of operation. The maintenance technician confirmed that the dry system was out of service at the time of the survey. Subsequent surveys revealed that the deficiency remained uncorrected, as the facility had not completed the necessary repairs or inspections to restore the sprinkler system to service. The facility had received a bid from a vendor but had not secured funding or payment to proceed with the repairs. During this period, the facility maintained a continuous fire watch as the sprinkler system remained nonfunctional.
Plan Of Correction
1. Absolute Fire Protection has been contacted to ensure that any and all necessary parts needed to fix the malfunctioning air compressor will be ordered and installed, so that the dry sprinkler system can be turned back on prior to the "substantial compliance" date of 1/30/2026. Documentation WAS provided to the extent and duration of the dry system being out of operation in the form of "fire walk" documentation, from the day the system went down through present day. 2. The Administrator will assist the Environmental Services Director in ensuring that Absolute Fire Protection is contacted for service and that payment will be secured for any and all necessary parts to ensure the malfunctioning air compressor is operational, which will then allow for the dry sprinkler system to be turned back on. 3. The results of these corrective actions will be reviewed at the facility's next two quarterly Quality Assurance Performance Improvement meetings to ensure compliance.
Lack of Fire Watch Policy for Sprinkler System Outage
Penalty
Summary
The facility failed to maintain a complete and accurate fire watch policy for situations when the sprinkler system is impaired or out of service for more than ten hours. During a document review, it was found that there was no policy in place addressing the procedures to follow in the event of a sprinkler system impairment or extended outage. This deficiency was confirmed during an interview with the Director of Nursing and the Director of Maintenance, who acknowledged the absence of such a policy. No information was provided regarding specific residents or their medical conditions in relation to this deficiency.
Plan Of Correction
The facility has a Fire Watch Policy that is available for review. The Fire Watch Policy will be placed in the Safety and Disaster Policy & Procedure Manual. The Environmental Services Director will be educated on the Fire Watch Policy. The Safety and Disaster Policy & Procedure Manual will be reviewed yearly, every July.
Failure to Provide Fire Watch and Staff Notification During Sprinkler System Outage
Penalty
Summary
The facility failed to ensure that when the sprinkler system was out of service for more than 10 hours in a 24-hour period, the affected areas were either evacuated or an approved fire watch was provided, as required by relevant fire safety codes. Record review showed that the annual dry sprinkler inspection revealed the system failed due to the attic dry system being capped and only six heads active. Despite this, the facility was not conducting fire watch in the unprotected areas, and required 'out of service' signage was not posted throughout the building, contrary to the facility's fire watch policy. Additionally, staff interviews indicated a lack of awareness regarding the non-operational status of the sprinkler system. A CNA stated she was not informed about the sprinkler system being out of service and expressed that this information was important for responding to a fire. Similarly, the ADON was unaware that a portion of the sprinkler system was not working. These findings demonstrate that both procedural and communication lapses contributed to the deficiency.
Plan Of Correction
1. The facility failed to follow its fire watch policy and procedures when the dry sprinkler system was not functioning properly. Per policy, the facility must either evacuate or initiate a fire watch if the system is non-operational for 10 or more hours within a 24-hour period. 2. Failure to implement fire watch procedures as required could have endangered the safety of all residents, staff, and visitors during a fire emergency. 3. Corrective actions have been taken as follows: - The facility promptly initiated fire watch procedures once the system malfunction was identified, including posting Out of Service signage and conducting regular monitoring rounds. - Excel Fire Protection replaced the 3-inch and 4-inch system piping. - Superiorland Electronics installed a second air compressor, replaced 12 feet of main sprinkler piping, and conducted a system water test. Two leaks (above a resident room and in the boiler room) were identified and repaired. - A trip test will be performed to confirm the full functionality of the system. - Documentation of all system repairs has been received from Excel and Superiorland. - All staff have been re-educated on the fire watch policy, including the requirement for timely implementation when the sprinkler system is out of service. - Superiorland Electronics will complete the hydrostatic testing of the system by 5/23/25. 4. The Administrator is responsible for ensuring fire watch policies and procedures are implemented without delay during any future system outage and for reporting compliance status to the Quality Assurance (QA) Committee.
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