Failure to Perform Required Sprinkler System Maintenance
Penalty
Summary
The facility failed to perform required annual and tri-annual maintenance and testing on its sprinkler systems, as mandated by NFPA 25. During a document review on February 4, 2025, it was discovered that the facility did not have documentation for the annual inspection of the wet system, including the main drain and control valves, nor for the dry system's annual trip test and the 3-year full flow trip test. This deficiency was confirmed during an exit conference with the Administrator and Maintenance Director, who acknowledged that the inspections were not performed.
Plan Of Correction
The facility will have a sprinkler inspection completed on 3/4/25. The maintenance staff will be educated on completing a sprinkler inspection annually. A quarterly audit will be completed to ensure a sprinkler inspection was completed. Audit results will be reported to the next QAPI meeting.