Failure to Maintain Automatic Sprinkler System
Penalty
Summary
The facility failed to maintain the automatic sprinkler system in compliance with NFPA 25 standards, as evidenced by two specific deficiencies. Firstly, during an observation on January 8, 2025, it was found that a drop ceiling grid was improperly wired to a sprinkler pipe in the Countryside hallway next to Room 312. This deficiency was confirmed through an interview with the Facility Administrator and Maintenance Director later that day. Additionally, the facility did not replace or recalibrate the gauges for the automatic sprinkler system within the last five years, affecting the entire facility. This was discovered during an inspection on the same day. The Facility Administrator and Maintenance Director confirmed this deficiency during an interview. These findings indicate a lapse in the regular maintenance and testing of the sprinkler system, as required by the relevant standards.
Plan Of Correction
Note that room 312 is Gardenside. The identified attached wire to the sprinkler pipe near room 312 was removed on the date of discovery. An inspection of the building will occur to identify non-compliant wires attached to sprinkler pipes and any issues will be corrected. Maintenance staff will receive training conducted by the maintenance director or designee related to areas of noncompliance related to sprinkler heads. Each neighborhood area will be randomly audited in several locations weekly for four weeks and then monthly for three months to ensure there are no issues of non-compliance related to sprinkler head violations. Results of audits will be presented to the QAPI committee each quarter for review to ensure any negative trends of non-compliance are addressed through a performance improvement plan. Firefighters are scheduled to do a sprinkler head inspection on January 21, 2025. Firefighters will replace all sprinkler head gauges during this inspection. Firefighters acknowledged the need to replace the sprinkler head gauges in advance of the five-year threshold. A recurring work order will be placed in the electronic work order system as a reminder to ensure sprinkler head gauges are replaced by January of 2030 unless issues arise. The maintenance manager will educate all maintenance team members on the sprinkler head inspection and gauge replacement schedule. The maintenance manager will submit Firefighters' completion report/invoice to the QAPI committee. Any identified issues will be reviewed by the committee for further review and recommendations.