Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain and inspect its sprinkler system as required, affecting the entire facility. During a document review on November 20, 2024, it was found that the fourth quarter sprinkler inspection revealed several deficiencies that had not been corrected. Specifically, the tampers in the backflow preventer pit were not reporting to the fire alarm panel, the FDC hydrotest was overdue, and the dry system main drain was improperly piped to a shower drain that could not handle the full flow from the drain. These issues were confirmed during an exit interview with the Administrator and the Maintenance Director. A follow-up onsite revisit conducted on January 8, 2025, confirmed that the same deficiencies remained unaddressed. The tampers in the backflow preventer pit still did not report to the fire alarm panel, the FDC hydrotest was still overdue, and the dry system main drain continued to be piped to a shower drain incapable of handling the full flow. These ongoing deficiencies were again confirmed during an exit interview with the Administrator and the Regional Maintenance Director.
Plan Of Correction
Plan of Correction for TAG K353: Sprinkler System Maintenance and Inspection 1. Deficiency: Based on document review and interview, it was determined the facility failed to maintain and inspect the sprinkler system, affecting the entire facility. Document review on November 20, 2024, at 8:00 a.m., revealed the following deficiencies noted during the fourth quarter sprinkler inspection, with no documentation of the correction of these issues: a. Tampers in the backflow preventer pit were not reporting to the fire alarm panel. b. FDC hydrotest is overdue. c. Dry system main drain is piped to a shower drain, which cannot handle the full flow from the drain (note: this was not considered a deficiency, but a note). Residents Affected: No residents were directly affected by these deficiencies. However, all residents have the potential to be affected if these issues with the sprinkler system are not addressed properly, as the sprinkler system is a key safety feature for the entire facility. 2. Corrective Action: a. The necessary repairs will be made to ensure that the tampers in the backflow preventer pit report to the fire alarm panel. This repair will be completed by 02/08/25. b. The FDC hydrotest was completed on 12/27/24. c. The issue with the dry system main drain was identified as a note by the inspector and is not considered a deficiency. An addendum to the original report will be obtained from the sprinkler inspection vendor indicating that the main drain item is not considered a "deficiency" and was identified as a note. This documentation will be available to review by the life safety inspector on the day of the revisit. 3. Monitoring: The Maintenance Director will ensure that the sprinkler system, including the backflow preventer and fire alarm panel connections, is fully functional and reporting correctly. A follow-up audit will be conducted on 02/08/25 to ensure all necessary corrections have been completed and that the sprinkler system is in full compliance. 4. Timeline: The repairs for the tampers in the backflow preventer pit will be completed by 02/08/25. The FDC hydrotest has been completed as of 12/27/24.