Missing Documentation for Required Sprinkler System Inspections
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain required documentation for its automatic sprinkler system. During document review and interview on April 30, 2026, at 10:50 a.m., the facility was unable to provide records showing that semi-annual inspections of valve supervisory switches had been completed, as required. At the same time, the facility also could not produce documentation of annual inspections for the sprinkler system control valves. The maintenance supervisor confirmed during the interview that the sprinkler system documentation for these required inspections was unavailable at the time of the survey. No residents or specific patient conditions were mentioned in the report, and the deficiency centered solely on missing inspection and maintenance records for the fire sprinkler system components.
Plan Of Correction
Completion Date: 05/29/2026 Status: APPROVED Date: 05/20/2026 Maintenance department was educated on the need for the sprinkler system to be inspected and tested at regular intervals that includes semi annual for valve supervisory switches and annual control valves. The semi annual inspection will be scheduled to be completed per NFPA-0100 25. The annual control valve inspection will be scheduled to be completed per NFPA-0100 25. Random audits will be completed by the Administrator and/or designee monthly for 6 months to assure that semi annual valve supervisory switched and annual control valve testing was completed. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine compliance or need for continuation of audits.
Penalty
Surveyors identified that the facility failed to maintain required inspection and testing of its automatic sprinkler system in accordance with NFPA standards. Record review showed only one documented sprinkler inspection within the prior year, and no additional inspection records were produced despite multiple requests during the survey. The Maintenance Director confirmed that no other sprinkler inspection documentation was available, indicating that ongoing required inspections were not documented for all residents in the facility.
Failure to Maintain Required Sprinkler System Inspection Documentation
Penalty
Summary
The facility failed to properly maintain its automatic sprinkler system in accordance with NFPA 101 (2012) and NFPA 25 (2010), affecting all 67 residents in the building. During record review on 03/25/26 beginning at 8:45 A.M., surveyors found only one documented sprinkler inspection within the previous 12 months, dated 04/23/25. Additional documentation of required inspections was requested at the entrance conference at 8:40 A.M., and again at 9:35 A.M. and 10:10 A.M., but no further records were provided by the time of exit. An interview with the Maintenance Director confirmed that there were no other sprinkler inspection records available, verifying the lack of documented ongoing inspection and maintenance of the sprinkler system. No specific resident medical histories or conditions at the time of the deficiency were described in the report.
Plan Of Correction
1.Based on record review, observation and interview, no residents experienced negative outcomes related to sprinkler system deficiencies. The facility failed to ensure sprinkler system inspection, testing, and maintenance were completed and documented in accordance with NFPA 25. Findings included lack of complete inspection documentation within the required timeframe and identified physical deficiencies (including missing escutcheon plates). 2.The Medical Director was notified by LNHA on 03/26/2026 that the facility failed to ensure sprinkler system inspections, testing, and maintenance were completed and documented in accordance with NFPA 101 and NFPA 25 requirements. 3.Sprinkler system inspection, testing, and maintenance will be completed by a contracted fire protection vendor on or before 04/30/2026. This will include implementation of a full Inspection, Testing, and Maintenance (ITM) program in accordance with NFPA 25 (2010 Edition), including but not limited to: Completion of a full annual sprinkler system inspection in accordance with NFPA 25 §13.6.2.1. Quarterly testing of waterflow alarm devices and supervisory signals. Monthly and/or weekly inspection of control valves, gauges, and system condition as applicable. Five-year internal pipe inspection (obstruction investigation) if due. Inspection of all sprinkler heads to ensure no damage, corrosion, paint, loading, obstruction, or missing escutcheon plates. Verification that all components are installed correctly and maintained in reliable operating condition. All identified physical deficiencies (including missing escutcheon plates and any additional deficiencies discovered during inspection) will be corrected on or before 04/30/2026. A comprehensive facility-wide sprinkler system inspection will be completed to ensure no additional deficiencies exist. All inspection, testing, and maintenance activities will be placed on an automatically recurring schedule by Administrator/designee to ensure ongoing compliance. 4.Documentation of all sprinkler system inspection, testing, and maintenance activities will be maintained onsite and readily available at the time of survey. The Maintenance Director/designee will conduct routine audits to verify completion of required inspection, testing, and maintenance (ITM) activities. Compliance will be reviewed in QAPI every quarter and as needed to ensure ongoing systemic compliance. 5.LNHA educated Maintenance Director on 03/26/2026 regarding the requirements for maintaining the facility's fire suppression equipment, as well as ensuring required completion of backflow device testing; and required escutcheon plates to sprinkler heads.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
