Failure to Maintain Sprinkler System Components
Penalty
Summary
The facility failed to maintain its automatic sprinkler system components, which affected the entire facility. During a document review on December 23, 2024, it was found that the sprinkler inspection report from November 8, 2024, identified deficiencies. Specifically, the sprinklers in the 'old part' of the building, dated 1974, were due for UL-Testing, and the Fire Department Connection (FDC) required hydrotesting. An exit interview with the Administrator and Maintenance Director confirmed these deficiencies. A subsequent onsite revisit on February 11, 2025, revealed that the issue with the sprinklers in the 'old part' of the building remained unresolved, as confirmed by the Administrator during the exit interview.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by this provider of the facts alleged, or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and/or state law. The plan of correction constitutes our credible allegation of compliance. 1. On 1/6/2025 the Maintenance Director contacted The Tustin Group to schedule UL testing for the sprinklers in the "old part" of the building. 2. On 1/31/2025 the Tustin Group gathered the make and model for heads on the "old part" of the building to order replacement parts for the upcoming UL testing. 3. On 2/11/2024 the Maintenance Director checked the most recent sprinkler inspection report for cited deficiencies. There were no other deficiencies. 4. On 2/11/2025 the NHA re-educated the maintenance team on correcting deficiencies cited following a sprinkler inspection. 5. The Maintenance Director/designee will conduct weekly audits for 4 weeks to verify that the deficiencies cited following an inspection are corrected timely. Results of the audits will be reviewed at the QAPI meeting held monthly.