Failure to Maintain Automatic Sprinkler System
Penalty
Summary
The facility failed to maintain the automatic sprinkler system as required, which was evidenced by a supervisory signal indicating a fire pump loss of power on the fire alarm panel. This issue was observed during an inspection on April 8, 2025, affecting all three floors of the facility. Although the facility had a new fire pump on site, it had not yet been installed. Previous fire alarm testing conducted on April 1, 2025, did not reveal any deficiencies. The deficiency was confirmed during an exit interview with the Facility Administrator and Facilities Manager.
Plan Of Correction
1. The facility has contracted with Beach Lake Sprinkler to replace the fire pump panel on the week of May 5, 2025. 2. The facility fire pump controller will be reviewed and updated as needed. 3. NHA will educate the Maintenance Director, to assure the fire pump is updated as needed. 4. Fire pump will be audited weekly x4 then monthly x3 by Maintenance Director/Designee to ensure fire alarm pump is up to date. Audits will be reviewed at QAPI for further recommendations.