Outdated Sprinkler System Inspection Records and Improper Storage Near Sprinkler Deflector
Penalty
Summary
The facility failed to maintain up-to-date inspection and testing records for its automatic sprinkler system as required by NFPA 25. During a record review and interview with the Administrator and Maintenance Director, it was found that the most recent 5-year inspection and testing documentation was dated 7/18/2019, making the records past due. The Maintenance Director confirmed that no more current records were available. This deficiency affected all 93 residents across four smoke compartments in the facility. Additionally, during an inspection of the physical environment, storage items were observed in the kitchen storage closet placed within 8 inches of a sprinkler deflector. This placement does not comply with NFPA 13 requirements, which prohibit obstructions within 18 inches of a sprinkler deflector that could prevent the sprinkler discharge pattern from fully developing. The Maintenance Director stated they were unaware of this regulation.
Plan Of Correction
K353 • How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. 5-year fire sprinkler inspection, main drain test on all systems, inspectors test/water flow test, back flush on all fire department connections, visual inspection of all fire heads and components, shutdown/reinstatement was performed 6/26/25 by GNA Firebrook Protection certified technician. 2. Boxes were removed from the kitchen storage room 6/25/25. • How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All patients have the ability to be affected by this deficient practice. • What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: 1. Maintenance director has put together an annual list of required testing, required to bring to January QA for review by all department heads/governing body. 2. Maintenance director is required to audit storage spaces for ceiling clearance once per week until reaching compliance for 3 months. • How the facility plans to monitor its performance to make sure that solutions are sustained: 1. Environmental services director will be responsible for scheduling and verifying all inspections are completed on a timely basis. All inspections and planned schedule will be brought to QA on a monthly basis for review until reaching 3 consecutive months with no concerns. 2. Environmental services director will bring his storage room ceiling clearance audit results to monthly QA until 3 consecutive months with no findings. • Include dates when corrective action will be completed: 1. Inspection completed 6/26/25. 2. Compliance for ceiling clearance on 6/25/25. How the facility plans to monitor its performance to make sure that solutions are sustained: 1. Environmental services director will be responsible for scheduling and verifying all inspections are completed on a timely basis. All inspections and planned schedule will be brought to QA on a monthly basis for review until reaching 3 consecutive months with no concerns. 2. Environmental services director will bring his storage room ceiling clearance audit results to monthly QA until 3 consecutive months with no findings. • Include dates when corrective action will be completed: 1. Inspection completed 6/26/25. 2. Compliance for ceiling clearance on 6/25/25.