Failure to Maintain Fire Sprinkler System Documentation
Penalty
Summary
The facility failed to maintain its automatic fire sprinkler system in accordance with NFPA 101 standards. During a record review conducted on March 19, 2025, between 10:00 AM and 2:00 PM, it was discovered that there was no documentation available for the 5-year hydrostatic test of the fire department connection (FDC) and the 5-year internal inspection of the fire-line backflow preventer. These deficiencies were identified during a review with the Maintenance Assistant, who acknowledged the findings. The issues were subsequently discussed with the Administrator and the Maintenance Director during the exit conference on the same day at 3:15 PM.
Plan Of Correction
K353 NFPA 101 SPRINKLER SYSTEM - MAINTENANCE AND TESTING 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of having no documentation for the FDC 5-year hydrostatic test. The Maintenance Director or designee will acquire the documentation of proof that the FDC 5-year hydrostatic test was completed. 2) In the allegation of having no documentation for the fire-line backflow preventer 5-year internal inspection. The Maintenance Director or designee will acquire the documentation of proof that the fire-line backflow preventer 5-year internal inspection was completed. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: - Maintenance Director or designee will ensure that there is proper documentation for the FDC 5-year hydrostatic test is up to date and available for inspection. - Maintenance Director or designee will ensure that there is proper documentation for the fire-line backflow preventer 5-year internal inspection documentation is up to date and available for inspection. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction. Corrective action completion date: 4/19/25