Failure to Maintain and Document Sprinkler System Testing and Maintenance
Penalty
Summary
The facility failed to comply with NFPA 25 requirements for the inspection, testing, and maintenance of its automatic sprinkler system. During record review, it was found that the facility did not provide documentation showing that deficiencies identified during the annual sprinkler system inspection were corrected. Additionally, there was no documentation available to confirm that the required quarterly flow test of the automatic sprinkler system was completed for the first quarter of the year. Observation in the basement revealed three sprinkler gauges, one of which was dated from several years prior and two that were undated, with no documentation available regarding their installation or manufacture dates. These findings were confirmed through interviews with the Maintenance Assistant and Housekeeping/Laundry Manager.
Plan Of Correction
K353 #1 All items identified during the annual sprinkler testing of 12/23/2024 will be corrected by Summit Fire Protection on 5/22/25. A quarterly flow test was completed on 4/29/25 with no concerns. The gauges that were identified as requiring replacement will be replaced on 5/22/25 by Summit Fire Protection. #2 All residents have the potential of being affected by the deficient practice. All reports were reviewed and a corrective action repair visit was scheduled for 5/22/25. #3 Maintenance Director was educated to provide all paperwork and proof of Sprinkler System Testing in the Life Safety Manual. #4 Any further Sprinkler System Maintenance and Testing paperwork will be kept in the Life Safety Manual. #5 It will be the responsibility of the Maintenance Director and Administrator to ensure sustained compliance.