Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to meet the sprinkler system maintenance and testing requirements as evidenced by an observation in the basement electric control room. During the survey conducted on April 8, 2025, at 10:30 a.m., it was observed that a fictional character figure, specifically a minion, was taped to the sprinkler line. This deficiency was confirmed through an interview with the maintenance director at the same time, indicating a lapse in adhering to the standards set by NFPA 25 for the inspection, testing, and maintenance of water-based fire protection systems.
Plan Of Correction
Fictional character was removed immediately when noted by life safety surveyor. Regional maintenance director educated administrator on regulation on sprinkler system maintenance and testing requirements on 4/15/2025. Administrator will educate housekeeping director and all housekeeping staff on sprinkler system maintenance and testing requirements by 5/14/2025. Maintenance director/designee will round weekly for the next four weeks to ensure compliance. Results of audit will be reviewed with administrator weekly.