Deficiencies in Sprinkler System Maintenance and Electrical Outlet Safety
Penalty
Summary
The facility failed to provide documentation that its sprinkler system, which had been in service for 50 years, met the testing requirements set by a recognized testing laboratory or had been replaced as required by NFPA 25. During review of inspection reports, it was found that the annual sprinkler inspection failed because the sprinklers were out of date, and laboratory testing indicated the sprinklers failed the water seal release test. The facility's records also showed that a significant number of sprinklers were due for testing or replacement, and the facility's preventative maintenance policy assigned responsibility for maintenance scheduling to the Maintenance Director. Additionally, the facility did not ensure that an electrical outlet at Nurse Station #2 was properly maintained, as an observation revealed that half of the faceplate cover was broken, exposing metal terminals. This was confirmed during an interview with the CMO, who stated he had not previously noticed the broken faceplate. The facility's policy and procedure for preventative maintenance was also reviewed in relation to this finding.
Plan Of Correction
K353 Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Corrective Action Initiated for those resident(s) found to have been affected by deficient practice: Upon notification of the deficient practice on 05/28/2025, the MS called to follow-up the fire sprinkler heads replacement schedule by vendor on 05/28/2025 and 06/13/2025 and by the ADM on 06/16/2025 and 06/17/2025. All sprinkler heads will be replaced pending approval of plans submitted by vendor to HCAI/OSHPD (Exhibit #2, Exhibit #s 5-8). 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: There was no other trend identified and no other residents were affected by this deficient practice. Measures put into place or systematic changes the facility will make to ensure the deficient practice does not occur: K353 Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Corrective Action Initiated for those resident(s) found to have been affected by deficient practice: Upon notification of the deficient practice on 05/28/2025, the MS called to follow-up the fire sprinkler heads replacement schedule by vendor on 05/28/2025 and 06/13/2025 and by the ADM on 06/16/2025 and 06/17/2025. All sprinkler heads will be replaced pending approval of plans submitted by vendor to HCAI/OSHPD (Exhibit #2, Exhibit #s 5-8). 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: There was no other trend identified and no other residents were affected by this deficient practice. Measures put into place or systematic changes the facility will make to ensure the deficient practice does not occur: On 05/28/2025, the ADM provided an in-service/re-education to MS regarding policies and procedures on Preventative Maintenance Program, ensuring the need for regular testing and maintenance of the sprinkler system for compliance and safety. Monitoring for the effectiveness and the sustainability of the corrective action put into place to correct the issue identified: An observational audit on the maintenance log for the sprinkler system will be done once a month for 3 months with Administrator/Designee. A summary of the identified trend of the audit will be brought to the monthly QA meeting for 3 months by MS for evaluation of the plan effectiveness and sustainability. Date of compliance: June 20, 2025 K511 Utilities - Gas and Electric CFR(s): NFPA 101 Corrective Action Initiated for those resident(s) found to have been affected by deficient practice: Upon notification of the deficient practice on 05/28/2025, the MS changed the faceplate of the electrical outlet at Nurse Station #2 on 05/28/2025. (Exhibit #3) 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: There was no other trend identified and no other residents were affected by this deficient practice. Measures put into place or systematic changes the facility will make to ensure the deficient practice does not occur: On 05/28/2025, the ADM provided an in-service/re-education to MS regarding policies and procedures on Preventative Maintenance Program, ensuring all electrical receptacles were maintained free of damage. Monitoring for the effectiveness and the sustainability of the corrective action put into place to correct the issue identified.