Failure to Document Five-Year Sprinkler System Inspection
Penalty
Summary
The facility failed to maintain their Automatic Fire Sprinkler System (AFSS) in accordance with NFPA 101 standards. During an inspection on April 8, 2025, it was observed that there was no documentation available for the required five-year internal backflow preventer inspection. This deficiency was identified during a record review conducted with the Maintenance Director, who acknowledged the findings. The lack of documentation for the inspection was discussed with the Maintenance Director during the exit conference on the same day.
Plan Of Correction
NFPA 101 ACTION(S) TAKEN TO CORRECT THE DEFICIENCY: The facility scheduled a 5-year sprinkler backflow on 4/16/2025 and completed on 4/17/2025. HOW OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE WILL BE IDENTIFIED: A full audit was completed to identify all residents with potential to be affected by the deficient practice. The potential for harm was minimal. MEASURES PUT INTO PLACE TO ENSURE THE SAME DEFICIENT PRACTICE DOES NOT REOCCUR: The Maintenance Director or Designee will conduct an audit on an annual basis to ensure the 5-year sprinkler backflow is in compliance. HOW THE CORRECTIVE ACTION WILL BE MONITORED: The Maintenance Director will audit compliance with the 5-year sprinkler back annually for compliance. Findings will be brought to QAPI.