Failure to Maintain Sprinkler System Documentation
Penalty
Summary
The facility failed to maintain its sprinkler system in accordance with NFPA 25 standards, affecting the entire facility. During an observation on January 22, 2025, at 11:10 a.m., it was found that the facility could not provide documentation for sample testing data or the replacement of sprinklers that had been in service for 50 years. The sprinkler report indicated that sprinkler heads dated back to 1974 and 1975 were still in use throughout the facility. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager on the same day at 12:30 p.m., where they acknowledged the lack of documentation for the required 50-year sample testing or replacement.
Plan Of Correction
1. NHA and Maintenance Director could not retroactively complete the sample testing for the sprinklers. 2. The whole house audit was done of the sprinkler system to identify which heads are from 1974 and 1975. 3. The maintenance director was reeducated on the importance of sprinkler testing/ Replacement of sprinkler heads every 50 years. Sprinkler heads are being replaced when they hit the 50-year mark. 4. A one-time audit was completed of sprinkler heads due for replacement to make sure replacement was completed. The results will be submitted to the QAPI committee for review and analysis of the need of ongoing monitoring.