Failure to Document Monthly Sprinkler Gauge Inspections
Penalty
Summary
The facility failed to comply with the NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, specifically regarding the inspection of sprinkler system gauges. A review of the facility's records showed that there was no documentation of monthly inspections of the gauges for the wet sprinkler system. This deficiency was confirmed during an interview with a staff member, who acknowledged the absence of the required documentation. This oversight had the potential to affect all 74 residents at the facility.
Plan Of Correction
1. Corrective Action of Areas Affected: The Director of Maintenance has completed the required monthly sprinkler gauge inspection for December. The US FOIA (b) (6) has been in-serviced on the need to ensure this inspection occurs on a monthly basis. 2. Other Areas Affected: All residents have the potential to be affected by this deficient practice. The Director of Maintenance is responsible to ensure the sprinkler gauge is inspected on a monthly basis and provide the report to the Administrator. 3. Systemic Changes to Prevent Future Occurrences: Sprinkler gauge inspection has been placed on a monthly Preventive Maintenance inspection by the Director of Maintenance. 4. Monitoring of Corrective Action: The Director of Maintenance will submit a report monthly x 3 months at the monthly Quality Assurance Improvement Meetings for review and recommendations.