Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain its automatic sprinkler system components, impacting the entire facility. During a document review on April 15, 2025, it was found that the sprinkler inspection report from April 2, 2025, identified several deficiencies. The wet system's tamper in the pit did not report to the panel during the inspection, and it was noted that the pit consistently fills with water, requiring the facility to monitor and pump out the water for proper inspection and maintenance. Additionally, the dry system's last Fire Department Connection (FDC) hydrotest date was unknown, necessitating an immediate test. These deficiencies were confirmed during an exit interview with the Administrator, Maintenance Director, and Regional VP of Operations.
Plan Of Correction
1) A. Wet System - The tampers in the report to the alarm panel. B. Dry System - The Maintenance Director or Designee will ensure to FDC hydrotest date is confirmed and completed. 2) The Maintenance Director and/or designee inspected the tampers, confirmed reporting to the alarm system, and the pit does not have accumulating water. 3) To prevent the potential for reoccurrence, the Administrator educated the Maintenance Director and/or designee on the importance of ensuring the tampers report to the alarm system and the pit does not have accumulating water. 4) To monitor and maintain ongoing compliance, the Maintenance Director and/or designee will inspect the pit weekly for one month, and monthly for the next two months. If an issue is identified, the vendor will be contacted to restore the tamper connection to the alarm and assure there is no accumulation of water in the pit. Findings will be reported to facility QAPI for continued review and recommendations.