Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain its automatic sprinkler system in accordance with NFPA 25 standards, as evidenced by multiple deficiencies observed and documented. On February 3, 2025, a document review revealed that the facility did not perform the semi-annual sprinkler system inspection due in August 2024 and failed to correct deficiencies noted during the annual fire pump inspection. Interviews with the Facility Administrator and Director of Maintenance confirmed the absence of documentation for these inspections and corrections. Additionally, several physical deficiencies were observed, including a sprinkler head not flush with the ceiling tile in central supply, a missing ceiling tile across from resident room 409 Main, and another missing ceiling tile in the 2 West electrical panel closet. These observations were confirmed through interviews with the Facility Administrator and Maintenance Director. The lack of proper maintenance and inspection documentation, along with the physical deficiencies, affected the entire facility's compliance with fire safety standards.
Plan Of Correction
353 main 1. A new vendor was contracted to ensure a regulatory semi-annual sprinkler inspection is completed. A new vendor was contracted to correct deficiencies identified in annual fire pump inspections. The sprinkler head in central supply was corrected to be flush with the ceiling tile. The ceiling tile in the west 2 electrical closet was corrected. Ceiling tile across from resident room 409 was corrected. 2. The Director of Maintenance or designee will monitor alongside the vendor to ensure continued semi-annual inspections and corrections are completed. 355 main 1. A new vendor was contracted to complete the annual fire extinguisher inspection. The inspections are always performed by certified vendors/persons as identified by all past documentation available to the surveyors. 2. The Director of Maintenance or designee will monitor alongside the vendor to ensure continued annual inspections of fire extinguishers are completed. 1. A new vendor was contracted to ensure a regulatory semi-annual sprinkler inspection is completed. A new vendor was contracted to correct deficiencies identified in annual fire pump inspections. The ceiling tile was corrected. 2. The Director of Maintenance or designee will monitor alongside the vendor to ensure continued semi-annual inspections and corrections are completed. 355 1. A new vendor was contracted to complete the annual fire extinguisher inspection. The inspections are always performed by certified vendors/persons as identified by all past documentation available to the surveyors. 2. The Director of Maintenance or designee will monitor alongside the vendor to ensure continued annual inspections of fire extinguishers are completed.