Sprinkler System Maintenance Deficiency
Summary
The facility failed to inspect, test, and maintain all components of the sprinkler system in accordance with the 2011 NFPA 25 standards. During a life safety survey conducted on December 16 and 17, 2024, it was observed that sprinkler heads were missing escutcheons in several areas, including the 1st floor IT room, the secondary ATS room next to the IT room, the 1st floor oxygen storage room, and the exit passageway leading from the 1st floor landing of stair C. Additionally, there was no record of the required 5-year internal pipe inspection in the maintenance, testing, and inspection records. These deficiencies were acknowledged by the Director of Maintenance at the time of the survey.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 Element 1 Corrective Action: 1) The facility installed escutcheon plates on the identified sprinklers on the 1st floor next to the IT room, the secondary ATS room on the 1st floor next to the IT room, the 1st floor oxygen storage room, and the exit passageway leading from the 1st floor landing of stair C. 2) The facility engaged our licensed sprinkler inspection and testing vendor to complete the 5 year internal pipe inspection; testing was completed on (MONTH) 8, 2025. Element 2: While no residents were affected by this practice, the potential exists for residents to be affected by this practice. Element 3 Systemic Changes: All maintenance personnel will be educated on the new policy requirements to maintain the sprinkler system. Training will include: Inspection and testing requirements for the Automatic Sprinkler system in accordance with 2012 NFPA 25, and the maintenance of all components of the sprinkler system. An audit tool was developed to monitor compliance. Element 4: Monitoring of Corrective Action: The maintenance director will audit all sprinkler heads monthly to ensure no sprinkler heads are obstructed. The maintenance director will report all findings to the administrator on a monthly basis. The maintenance director will submit results of the audit to the QAPI Committee on a quarterly basis for 3 quarters/6 months. The QAPI Committee will determine if further action is required. Element 5: Person Responsible: Maintenance director
Penalty
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
