Deficiency in Sprinkler System Supervisory Signal Monitoring
Summary
The facility failed to ensure that automatic sprinkler system supervisory attachments were properly installed and monitored for integrity in accordance with NFPA 72 requirements. During a record review, it was found that the annual dry sprinkler inspection indicated the system had been capped and failed the inspection. Additionally, review of the fire alarm control panel (FACP) revealed that supervisory and/or trouble alarms were present, indicating that a portion of the sprinkler system had been shut down. These findings were confirmed by the Maintenance Director at the time of discovery. No information about specific residents or their medical conditions was provided in the report.
Plan Of Correction
1. The facility failed to maintain the automatic sprinkler system's supervisory attachment panel in proper working condition. 2. A malfunctioning supervisory panel compromises the effectiveness of the sprinkler system, potentially placing all residents, staff, and visitors at risk during a fire emergency. 3. Corrective actions are underway as follows: - Superiorland Electronics has been contacted and has ordered a new dry pipe valve and a new control valve equipped with a tamper switch. - Once parts are installed, the system will be tested to ensure full functionality. - The Maintenance Director has been educated on the importance of maintaining a properly functioning automatic sprinkler system supervisory panel. 4. The Maintenance Director is responsible for ensuring the panel remains operational and will report system status and maintenance updates to the Quality Assurance (QA) Committee.
Penalty
The facility failed to maintain the automatic sprinkler system, as evidenced by a supervisory signal indicating a fire pump loss of power on the fire alarm panel. This affected all three floors, and although a new fire pump was on site, it had not been installed. Previous fire alarm testing found no deficiencies. The issue was confirmed during an exit interview with the Facility Administrator and Facilities Manager.
The facility's sprinkler system was found to have two unsupervised outside screw and yoke (OS&Y) valves, which could prevent staff from knowing if the system was impaired. The domestic and sprinkler riser water line shared the same main water line from the city, and the main water riser room was located in a corporate office storage room. This deficiency had the potential to affect 88 residents.
Failure to Maintain Automatic Sprinkler System
Penalty
Summary
The facility failed to maintain the automatic sprinkler system as required, which was evidenced by a supervisory signal indicating a fire pump loss of power on the fire alarm panel. This issue was observed during an inspection on April 8, 2025, affecting all three floors of the facility. Although the facility had a new fire pump on site, it had not yet been installed. Previous fire alarm testing conducted on April 1, 2025, did not reveal any deficiencies. The deficiency was confirmed during an exit interview with the Facility Administrator and Facilities Manager.
Plan Of Correction
1. The facility has contracted with Beach Lake Sprinkler to replace the fire pump panel on the week of May 5, 2025. 2. The facility fire pump controller will be reviewed and updated as needed. 3. NHA will educate the Maintenance Director, to assure the fire pump is updated as needed. 4. Fire pump will be audited weekly x4 then monthly x3 by Maintenance Director/Designee to ensure fire alarm pump is up to date. Audits will be reviewed at QAPI for further recommendations.
Unsupervised Sprinkler System Valves
Penalty
Summary
The facility failed to ensure that the sprinkler system was electronically supervised in accordance with NFPA 101, 2012 Edition, Section 19.3.5.1 and section 9.7. During an observation, it was found that the domestic and sprinkler riser water line shared the same main water line from the city. The sprinkler system's water line had two unsupervised outside screw and yoke (OS&Y) valves. Without supervisory devices on these OS&Y valves, the nursing home staff would not be alerted if the sprinkler system was impaired, such as if the water flow was cut off. This deficiency had the potential to affect 88 residents. The main water riser room for both the nursing home and corporate offices was located in a corporate office storage room. During an interview, it was confirmed that the unsupervised OS&Y valves were on the water line for the facility's sprinkler system.
Plan Of Correction
Two tamper switches and two fire sprinkler control valve signs on the OS&Y valves coming from the street were installed. All residents have the potential to be affected. The Maintenance Director will make monthly rounds to ensure all the automatic sprinkler system supervisory attachments are properly installed. The Maintenance Director will report the results of these audits to the Administrator on a monthly basis. The Maintenance Director will review the findings of the monthly audits at the Quarterly QAPI Meeting for the next 2 quarters.
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