Improper Support of Sprinkler Piping by Electrical Conduit in Two Smoke Compartments
Summary
Surveyors found that the facility failed to properly maintain its automatic sprinkler system in accordance with NFPA 25 and NFPA 101 requirements. During observations on April 27, 2026, an electrical MC wire conduit was seen resting directly on sprinkler piping above the ceiling tiles in the elevator 4 lobby on the 3 East unit at 9:15 a.m. A similar condition was observed at 9:35 a.m. above the ceiling tiles in the elevator 4 lobby on the 2 East unit, where another electrical MC wire conduit was resting on sprinkler lines. These deficiencies affected two of fifteen smoke compartments. In an interview on April 28, 2026, at 1 p.m., the Facility Administrator and Director of Maintenance confirmed the identified automatic sprinkler system deficiencies. No residents or specific patient conditions were mentioned in the report, and the deficiency pertains solely to the physical environment and maintenance of the sprinkler system components in the identified areas.
Plan Of Correction
1. On April 27, 2026, the electrical MC wire conduit resting on the sprinkler piping above the ceiling tiles in the Elevator 4 Lobby on 3 East was removed and Elevator 4 Lobby on 2 East was removed and properly supported to eliminate contact with the sprinkler system piping. The Director of Maintenance verified that no damage occurred to the sprinkler piping or system 2. The Director of Maintenance conducted a facility-wide inspection above accessible ceiling spaces to identify any additional instances of electrical conduit, wiring, or other materials resting on sprinkler piping. Any additional findings identified during the inspection were immediately corrected at the time of discovery. 3. The Director of Maintenance educated maintenance department on requirements prohibiting any item from being supported by or resting on sprinkler piping. 4. The Director of Maintenance or designee will conduct weekly inspections x4 weeks and then monthly after, of a minimum of five random above-ceiling locations throughout the facility to verify compliance. Findings will be documented and reviewed during the facility's (QAPI) meetings monthly for three months
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.
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