Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its sprinkler systems, which affected the entire facility. During a document review and interview conducted on December 23, 2024, it was found that the Annual Sprinkler Report dated October 24, 2024, identified a deficiency. Specifically, a hydrostatic test revealed a leak in the fire department connection piping. The necessary parts for repair were on order, but the repairs had not yet been completed. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director.
Plan Of Correction
NFPA 101 Sprinkler System - Maintenance and Testing Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. 1. Anticipated completion date for repair of sprinkler connection piping is 02/10/2025. A Limited Time Waiver will be submitted if repairs extend past completion date of 02/10/2025. 2. To identify other residents, facility reviewed last 3 months of sprinkler system reports. 3. To prevent this from reoccurring, NHA/designee reeducated maintenance staff on sprinkler system deficiencies. 4. Ongoing monitoring for compliance, Maintenance Director/designee will audit sprinkler system inspections for deficiencies weekly for 1 month then once monthly for two months. Results will be presented to QAPI committee for review and revision as needed.