Sprinkler System Water Flow Alarm Failure
Penalty
Summary
The facility failed to maintain its automatic sprinkler system in accordance with NFPA 25 and NFPA 101 Life Safety Code requirements. During a tour and inspection, the water flow test was conducted at the inspector test valve located in an exterior electrical closet near the generator. The test revealed that the water flow alarm did not activate within the required 90 seconds, as the water flow was tested for over 90 seconds without initiating the alarm. The last documented water flow test was during the annual inspection on 5/16/25. Staff interviewed during the inspection were unaware that the water flow alarm was not functioning as required. This deficiency affected all 90 residents and all ten smoke compartments in the facility, as the lack of a functioning water flow alarm could delay sprinkler protection in the event of a fire. Records of system design, maintenance, inspection, and testing were maintained, but the failure to ensure the water flow alarm's proper operation led to the cited deficiency.
Plan Of Correction
The facility recognizes the importance of maintaining the Sprinkler System. The facility shall continue to maintain the Sprinkler System, including the water flow test. The repair and retest of the Sprinkler System was conducted and completed by Environmental Services Supervisor June 9, 2025. The facility will continue to complete the Sprinkler System flow test monthly in July, August, and September—then will revert back to normal quarterly testing in October. Further issues regarding the facility Sprinkler System will be received during the QA process and brought to the QAPI Committee for review and discussion at least quarterly, or as necessary. The Administrator, Environmental Services Supervisor, QA Manager, and maintenance staff shall be responsible for monitoring and ongoing compliance. This page is purposefully blank.