Failure to Maintain Fire Sprinkler System per NFPA Standards
Penalty
Summary
The facility failed to maintain its automatic fire sprinkler system (AFSS) in accordance with NFPA 101 and NFPA 25 standards. During a facility tour with the Facility Manager, surveyors observed multiple deficiencies in the sprinkler system, including corroded and dust-loaded sprinkler heads. Specifically, all 14 pendant sprinkler heads in the front porch and exterior covered drive were found to be corroded, as well as 2 of 3 pendant sprinkler heads in the laundry washroom. Additionally, 1 of 2 upright sprinkler heads behind the dryers was corroded, and another upright sprinkler head in the same area was loaded with dust. These findings were confirmed through interviews with the Facility Manager conducted at the time of observation. The report documents that the facility did not meet the required standards for inspection, testing, and maintenance of the AFSS, as outlined in the referenced NFPA codes. No information about residents or their medical conditions is included in the report.
Plan Of Correction
The facility Administrator/Designee contacted a vendor to service the 14 pendant sprinkler heads located at the front porch and cover drive, the 2 pendant sprinkler heads located in the laundry washroom, the 1 upright sprinkler head located behind the dryers, and the 1 sprinkler head covered with dust behind the dryers, as it relates to meeting compliance with NFPA 101. No residents were found to be affected by this alleged deficient practice. The Nursing Home Administrator educated the Maintenance staff on maintaining sprinkler heads in accordance with NFPA 101, which includes maintaining them free of dust or corrosion. The Nursing Home Administrator/Designee will conduct weekly audits for 3 months on 5 sprinkler heads to ensure they are maintained in accordance with NFPA 101, including being free of dust and corrosion. The findings of these audits will be reported in the next risk management/Quality assurance committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring. The facility Administrator/Designee contacted a vendor to service the 14 pendant sprinkler heads located at the front porch and cover drive, the 2 pendant sprinkler heads located in the laundry washroom, the 1 upright sprinkler head located behind the dryers, and the 1 sprinkler head covered with dust behind the dryers, as it relates to meeting compliance with NFPA 101. No residents were found to be affected by this alleged deficient practice. The Nursing Home Administrator educated the Maintenance staff on maintaining sprinkler heads in accordance with NFPA 101, which includes maintaining them free of dust or corrosion. The Nursing Home Administrator/Designee will conduct weekly audits for 3 months on 5 sprinkler heads to ensure they are maintained in accordance with NFPA 101, including being free of dust and corrosion. The findings of these audits will be reported in the next risk management/Quality assurance committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring.