Failure to Maintain and Test Sprinkler System Gauges
Penalty
Summary
During an unannounced Fire & Life Safety relicensure survey, surveyors identified that the facility failed to maintain its automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) 101 standards. Specifically, the sprinkler gauge on the backflow and the gauges on the riser were observed to be dated from 2019, indicating that they had not been replaced or tested within the required five-year interval. Documentation provided by the facility did not include evidence of the mandatory five-year gauge testing. The deficiency was confirmed through record review, direct observation, and staff interviews. The Maintenance Director, who accompanied the surveyors during the facility tour, acknowledged the findings and stated that he was unaware if the gauges had been tested as required. Photographic evidence was obtained to support the observations made during the survey. The report references multiple applicable codes and standards, including NFPA 101 (2021 Edition), NFPA 13 (2019 Edition), and NFPA 25 (2020 Edition), all of which require regular inspection, testing, and maintenance of water-based fire protection systems. The lack of current testing records and outdated gauges constituted a failure to meet these licensure requirements. No information regarding specific residents or their conditions was included in the report.
Plan Of Correction
No individual residents appear to be affected as no residents were noted. All residents have the potential to be affected. The maintenance director contacted a third-party vendor, and all three identified gauges were replaced on 07/10/2025. Re-education will be completed by the administrator with the maintenance staff regarding maintaining the automatic fire sprinkler system in accordance with NFPA 101 standards by 07/25/2025. The Maintenance Director will audit the sprinkler system to ensure it is maintained in accordance with NFPA 101 standards monthly for three months. Results of the audits will be reviewed by the QAPI committee monthly for three months and randomly thereafter. Date of completion 07/25/2025.