Deficient Sprinkler System Maintenance and Missing Signage
Summary
The facility failed to maintain its automatic sprinkler system in accordance with NFPA 25 and NFPA 13 standards. During a tour and document review, surveyors observed that two sprinklers located at the front entrance of the facility had accumulated dust and debris on their bodies and deflectors. Staff confirmed that these components were typically cleaned on a monthly basis. Additionally, the annual sprinkler system testing record indicated a failed test due to missing required signage for the control valves and the fire department connection (FDC) servicing the building. Further observations revealed that the FDC on the riser along the southwest side of the building was missing identification signage, and the control valve in the same area also lacked the necessary signage. Staff confirmed these findings and stated that the facility was in the process of obtaining new signs. These deficiencies affected all 92 residents and all six smoke compartments within the facility.
Plan Of Correction
K 353 - Sprinkler System Maintenance and Testing How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: • The facility has immediately removed dust and debris on the exterior sprinklers. • The required signage for the fire department connection and control valve were installed on 4/2/25 by the EVS Director. 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 residents have the potential to be affected. • A full facility-wide sprinkler system inspection has been conducted to identify any additional deficiencies. No other deficiencies have been identified. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: • A monthly maintenance checklist will be completed by the EVS Director to ensure that all sprinkler system components are clean and free of debris. 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: • A monthly maintenance checklist will be completed by the EVS Director to ensure that all sprinkler system components are clean and free of debris. • Results will be reviewed in the QAPI meetings for ongoing compliance oversight. Date of Compliance 4/18/25
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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