Failure to Maintain and Document Quarterly Sprinkler System Inspections
Penalty
Summary
The facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 25 requirements. During a record review and interview with the Maintenance Director, it was found that the facility could not provide records of quarterly sprinkler inspections and testing for the first, second, and fourth quarters of the year. Only the third quarter inspection record was available. The Maintenance Director stated that the inspections and testing are performed in-house and that no external vendor had been used for these services. This deficiency affected all 77 residents across three smoke compartments. The lack of required documentation for quarterly inspections and testing was identified during the survey, and the absence of these records could result in a malfunctioning fire sprinkler system in the event of a fire. The findings were based solely on the review of records and staff interview, with no mention of any specific incidents involving residents at the time of the deficiency.
Plan Of Correction
Corrective Action Facility renewed the contract with the sprinkler company. Moving forward, the facility will make sure that sprinkler inspections are done by a professional company on a quarterly basis. Maintenance director will make sure that there will be no quarterly missing inspections. He will make sure that it is done by a contracted professional vendor. Identify other residents. All other residents have the potential to be affected by this deficient practice, so the facility will ensure that fire sprinklers are inspected on a quarterly basis by a professional vendor. Maintenance director and administrator made a walk-through and made sure that this deficiency is not affecting any other areas of the facility. Systemic Changes As a systemic change, the facility will add a quarterly sprinkler inspection into the safety committee action list. Team members will monitor and also check the maintenance records for compliance. Any discrepancy will be brought to the maintenance director and administrator immediately. Monitoring Process Maintenance supervisor will monitor for compliance on a monthly basis. Administrator will oversee the process with the help of the safety committee members. QA Process This plan of correction is integrated into the monthly QA committee for its effectiveness and completeness. Completion Date This plan of correction was completed on 04/18/2025.