Failure to Maintain Sprinkler System Inspection Documentation
Penalty
Summary
Surveyors determined that the facility failed to maintain required documentation for its automatic sprinkler system components. During a document review, it was found that records for the annual sprinkler inspection, annual main drain test, annual dry system trip test, and the 3-year full-flow trip test were missing. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director, who acknowledged the absence of the necessary inspection and testing documentation for the sprinkler system, which affects the entire facility. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
The annual sprinkler inspection was completed by vendor on 7/7/2025. Documents were sent to surveyor and placed in Life Safety binder. Maintenance director/designee in-serviced on tag K 0353 with focus on ensuring inspections are completed timely and kept in Life Safety binder. Maintenance Director/designee will complete weekly sprinkler inspections x 4 weeks, monthly x 2. Findings will be reported to QI committee monthly x 3 months.