Failure to Maintain Sprinkler System Components
Penalty
Summary
The facility failed to maintain automatic sprinkler system components, affecting the entire facility. During a document review on December 3, 2024, it was discovered that the October 2024 sprinkler inspection report listed a deficiency that had not been corrected by the time of the survey. Specifically, there was no record of a Fire Department Connection (FDC) hydrotest, which was required to be conducted on July 19, 2024, and September 16, 2024. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day.
Plan Of Correction
0353 FDC hydrotest completed. Maintenance Staff and vendor educated to timely repairs following inspections. NHA will audit that Maintenance Director schedules all repairs with vendor immediately following inspections so repairs will be made timely.