Failure to Maintain Automatic Sprinkler System
Penalty
Summary
The facility failed to maintain its automatic sprinkler system, as evidenced by an observation on January 13, 2025. The sprinkler gauges were found to be dated 2019, and the facility was unable to provide documentation that these gauges had been replaced or tested against a calibrated gauge within the last five years. This deficiency was confirmed during an interview with the Facility Administrator and Maintenance Director, indicating a lapse in the required maintenance and testing of the sprinkler system, which affects the entire facility.
Plan Of Correction
The automatic sprinkler gauges dated 2019 were replaced by an outside vendor on January 20, 2025. The Director of Maintenance and the maintenance staff were educated by the Administrator on the importance of ensuring that the fire sprinkler gauges need to be tested or replaced every five years. The Director of Maintenance or designee will pre-schedule with the outside vendor to ensure the five-year test and/or replace regulation.