Failure to Maintain Automatic Sprinkler System
Penalty
Summary
The facility failed to maintain its automatic sprinkler system in compliance with NFPA 25 standards, as evidenced by document review, observation, and interview. On January 7, 2025, it was found that the facility could not provide documentation for sprinkler system inspections conducted after February 7, 2024. Additionally, the facility did not change or recalibrate the sprinkler system gauges, which had expired in 2024. Furthermore, the facility failed to perform a required five-year internal pipe inspection within the last five years. These deficiencies were confirmed during an interview with the Facility Administrator and the Maintenance Director.
Plan Of Correction
The five-year internal pipe inspection, gauge replacement, and sprinkler inspection are scheduled to be completed on 01/24/2025. The Maintenance Director was educated on K 0353 and how it applies to Patriot Village. The schedule maintenance items were added to the annual calendar. Any issues that arise from the inspection will be corrected. Results will be reviewed at the Quality Assurance Performance Improvement meeting.