Failure to Maintain and Inspect Sprinkler System
Penalty
Summary
The facility failed to maintain and inspect its sprinkler system as required, affecting the entire facility. During a document review on January 13, 2025, it was found that the facility could not provide documentation for a 3-year dry system full flow test and a 5-year internal valve and pipe inspection. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director.
Plan Of Correction
The proper documentation for the 3-year dry system full flow test and 5-year internal valve and pipe inspection was obtained from Metropolitan Fire Protection Co., Inc. The documentation will be kept on file and included in each annual documentation set as needed. Monthly audits will be done by the Maintenance Manager to ensure all documentation is current. All audits will be reviewed by the Director of Facilities and Plan Operations and submitted to the Quality Assurance Performance Improvement Committee monthly ongoing.