Deficiencies in Sprinkler System Maintenance and Documentation
Penalty
Summary
The facility failed to meet the requirements for maintaining and testing its sprinkler system as per NFPA 25 standards. During a document review on December 18, 2024, it was found that the facility did not have documentation for the 3-year full trip test of the sprinkler system, with the last recorded test being in June 2021. This was confirmed during an interview with the Administrator and Director of Maintenance. Additionally, the facility lacked documentation for repairs to the fire department connection, which was identified as deficient during a 5-year internal inspection on November 20, 2024. The deficiency noted that the fire department connection could not pressurize the system due to deterioration. Furthermore, an observation and interview on the same day revealed that the sprinkler piping system was missing a hydraulic nameplate. This was also confirmed during the exit conference with the facility's Administrator and Director of Maintenance. These deficiencies indicate a failure to maintain critical components of the fire protection system, which affects the entire system's functionality.
Plan Of Correction
The facility reviewed sprinkler inspection reports to establish the last completed 3 year full trip test. The 3 year full trip test was completed on 5/10/2023 with the annual sprinkler inspection that year. This documentation is filed in the life safety survey book for review. The facility reviewed the deficiencies from the 5 year hydrostatic fire department connection testing inspection. This 5 year testing was completed on 11/20/24. The facility is developing a plan of action for the 5 year testing inspection cited summary. The facility is actively working with the sprinkler contractor and the local fire department to determine the best corrective action. In the interim, the facility will meet with the local fire chief to review the concerns from the testing for both awareness and planning, should the FDC be needed. The facility to request a TLW to address these concerns. The facility sprinkler system is a pipe system and will be labeled as a pipe system, by the sprinkler system vendor, by 2/04/2025. The facility will complete an audit of the sprinkler inspection reports from 2024 to ensure deficiencies have been addressed. The sprinkler inspections occurred on the following dates: 1/8/24 quarterly, 4/2/24 annual, 7/3/24 quarterly, 10/3/24 quarterly, and 1/6/25 quarterly. The annual sprinkler inspection for 2025 is anticipated completion by 4/30/2025. The reports will be filed in the facility life safety book. The facility is requesting a TLW for completion of the work that is needed for the FDC. Anticipated completion of this work would be 6/18/2025, as it is seasonal and greater external planning needed due to the location and correction of the FDC. Quarterly audits of the sprinkler reports will be completed by maintenance. Findings of the audits will be reported to QAPI for 9 months.