Other·May 17, 2023

K353 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked b) Who provided system test c) Water system supply source Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 T22 72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 4/7/2023 at 3:30 pm, The California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding the facility’s sprinkler system/environment. The facility failed to maintain the automatic sprinklers systems (a set of pipes and devices that carry water through a building to spray it on a fire) in accordance with the "National Fire Protection Association 25 Standard for the Inspection, Testing and Maintaining of Water-based Fire Protection Systems" (NFPA 25, baseline for inspection, testing, and maintenance of water-based fire protection systems).The facility did not have a functioning sprinkler system to extinguish fires within the facility, housing 57 Patients As a result, this deficient practice placed 57 Patients, staff, and visitors at risk of fire-related injuries or death. A review of the facility's census report, dated 4/6/23, indicated there were 57 Patients residing in the facility. On 4/7/23, at 3:30 pm, during a concurrent interview, Licensed Vocational Nurse 1 (LVN 1) stated the facility had been on fire watch for two months due to the facility's sprinkler system water pipe was broken. On 4/7/23, at 3:33 pm, during an interview, LVN 1 stated the project to repair the facility's damaged sprinkler system has been halted due to the Inspector on Record (IOR-an independent inspector who verifies the contractors are following the architect's plans) not being present at the facility. LVN 1 stated the sprinkler system did not have water and that nursing staff (in general) was conducting fire watch every 30 minutes. On 4/7/23, at 3:40 pm, during an observation of the project site, there was construction equipment and pipes at the project site, but there were no construction staff. On 4/11/23, at 9:45 am, during an interview, the Project Contractor (PC) stated he received an emergency authorization two months ago (2/22/23) to work on the sprinkler system broken water pipes. The PC stated he did not have the construction plans or permit onsite. On 4/11/23, at 10:15 am, during an observation of the project site, there were four construction staff working on the pipes for the sprinkler system. On 4/11/23, at 11:45 am, during a telephone interview, the HCAI Supervisor (HS) stated on 2/22/23, he granted the PC an emergency authorization to repair the facility's sprinkler system broken water pipes. The HS stated he informed the PC to submit the plans for the project and provide the names of the design professionals (in general) who would be working on the project. The HS stated on 3/3/23, he (HS) gave the facility a stop work order (an order to stop fixing the facility's sprinkler system) until the PC obtained a plan from a licensed design professional (unidentified) for the sprinkler system project. The HS stated on 3/3/23, he (HS) revoked the facility's emergency authorization for the repair of the sprinkler system. The HS stated the project could not proceed with construction until the plans were approved, and a building permit was issued. The HS stated if the facility did not submit any plans for review by 3/29/23, the project to repair the broken pipes from the sprinkler system would be closed as non-compliance. On 4/18/23, at 3:50 pm, during an interview, the administrator stated that the sprinkler project plans were submitted to HCAI today (4/18/23) at 2 pm for approval. The ADM confirmed that the facility did not have approved plans nor a permit for the sprinkler system project. A review of the facility's maintenance service policy and procedure, dated 12/20/09, indicated the maintenance department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times. The policy indicated the maintenance personnel will maintain the fire alarm system in good working order. A review of the facility’s fire watch policy and procedure revised May 2011 indicated the fire watch procedure will be initiated if the fire alarm system fails for a portion or the entirety of the fire alarm system. The policy indicated the fire watch tours were initiated throughout the facility and would occur every 30-minute intervals, 24-hours a day. The facility failed to maintain the automatic sprinklers systems (a set of pipes and devices that carry water through a building to spray it on a fire) in accordance with the "National Fire Protection Association 25 Standard for the Inspection, Testing and Maintaining of Water-based Fire Protection Systems" (NFPA 25, baseline for inspection, testing, and maintenance of water-based fire protection systems). The facility did not have a functioning sprinkler system to extinguish fires within the facility, housing 57 Patients As a result, this deficient practice placed 57 Patients, staff, and visitors at risk of fire-related injuries or death. This violation jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of 57 Patients.