Sprinkler System Deficiencies Unaddressed
Penalty
Summary
The facility failed to address deficiencies in its sprinkler system as identified by Johnson Control on February 29, 2024. These deficiencies included the need for replacement or recalibration of gauges, internal valve and pipe inspections, obstruction inspection, and replacement of a pipe with a pinhole over the kitchen. Additionally, the facility lacked a required fire department connection sign. These issues were confirmed through interviews with the Director of Maintenance on October 8, 2024, and again on December 9, 2024, when it was observed that the deficiencies had not been corrected.
Plan Of Correction
1. Johnson Control will be contacted to come out before 01/06/25: a. Replace or recalibrate gauges as needed b. Internal valve inspection c. Internal pipe inspection d. Obstruction inspection 2. Maintenance Director and Maintenance Staff will be educated on inspection and documentation requirements. Deficiencies identified by Johnson Control will be repaired. 3. An audit of the life safety book will be conducted quarterly for 12 months and bi-annually thereafter. 4. A fire department sign will be installed at the site of the connection. 5. Maintenance Director or Designee will conduct audits quarterly for 12 months, then biannually thereafter and filed in the LifeSafety. 6. Results of audits will be reported to the QAPI Committee for recommendations for review and analysis for ongoing monitoring.