Failure to Maintain Sprinkler System Inspection Documentation
Penalty
Summary
The facility failed to maintain the automatic sprinkler system as required, as evidenced by missing documentation for sprinkler system inspections in two instances. During a documentation review, it was found that there was no verification of any sprinkler inspections being performed in the last two quarters of the previous twelve months. The last recorded inspection was on October 15, 2024. This lack of documentation was confirmed in an interview with the Facility Maintenance Director, who acknowledged the absence of records for the required inspections.
Plan Of Correction
The quarterly sprinkler inspection will be scheduled by the Maintenance Director with completion expectation sprinkler inspection vendor by 8-8-25. I certify this document to be a true and correct statement of deficiencies and approved facility plan of correction for the above-identified facility survey.