Failure to Perform and Document Required 20-Year Sprinkler Head Testing
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to conduct the required 20-year testing of quick-response sprinkler heads in accordance with NFPA 25. During an interview and record review with the Director of Environmental Services (DES), the facility’s Life Safety materials binder was found to lack any record of a 20-year sprinkler test for the quick-response sprinkler heads installed throughout all four smoke compartments. The DES reported that the sprinklers were original to the building, which was constructed in 1999, and stated that the required testing may have been done in 2009, but there was no documentation on site to verify that the test had occurred. Further observation and interview showed that spare quick-response sprinkler heads in the facility’s stock had manufacturing dates such as 1996 and 1999 printed on them, confirming the age of the system components. The DES indicated that the outside testing company was unable to locate records from that time period to confirm whether the 20-year sprinkler testing had been performed. As a result, there was no evidence available to demonstrate that the required 20-year sprinkler head testing had been completed for the sprinkler system serving all four smoke compartments, as required by NFPA 25 and related Life Safety Code provisions.
Plan Of Correction
K353 – Sprinkler System Maintenance and Testing (NFPA 25) How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. There were no residents identified as directly affected by this deficient practice. Upon identification on 3/12/2026, the facility immediately contacted a licensed fire protection vendor to schedule the required 20-year sprinkler head testing. The sprinkler system remains fully operational and monitored, ensuring continued fire protection coverage while corrective actions are implemented. 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. On 3/13/2026, the Director of Environmental Services (DES) conducted a review of all available Life Safety documentation to confirm the absence of records for the 20-year sprinkler testing across all smoke compartments. The contracted licensed vendor has been engaged and performed testing on representative sprinkler heads throughout the facility in accordance with NFPA 25 standards on 3/19/2026. Response time, response time index and water seal release all passed. The report is dated 3/20/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. To prevent recurrence, the facility has implemented a Life Safety compliance tracking system that includes all required inspection, testing, and maintenance schedules in accordance with NFPA 25. On 3/13/2026, the DES re-educated staff on regulatory requirements for sprinkler system testing, including 20-year testing requirements for quick-response sprinkler heads. The facility will maintain all Life Safety documentation in a centralized, secure, and readily accessible binder and electronic file. Additionally, the facility will contract with a licensed fire protection vendor to ensure ongoing compliance with all inspection and testing requirements. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The DES or designee will track all required Life Safety inspections and testing through a compliance calendar and conduct monthly audits to ensure all required documentation is current and on file. Results of these audits will be reported to the Administrator and reviewed quarterly in the Quality Assurance and Performance Improvement (QAPI) committee meeting. Any identified gaps will be addressed immediately. The QAPI committee will monitor compliance until sustained. Include dates when corrective actions will be completed. The corrective action completion dates must be acceptable to the State Agency.
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