Failure to Complete Required Sprinkler System Inspections
Penalty
Summary
The facility failed to comply with sprinkler system maintenance regulations for two out of four systems, as identified during a document review and interview. Specifically, one of two required semi-annual supervisory switch inspections was not completed, and the annual trip test for the dry system was also not performed. These deficiencies were confirmed by the maintenance director during the survey, indicating that the necessary inspections had not been conducted at the time of review.
Plan Of Correction
Education will be provided to maintenance staff for schedule of annual trip test and semi-annual supervisory switch inspection. Annual inspection will be completed 8/14/25 and full flow trip dry system will be completed 8/15/25. Maintenance director or designee will audit compliance with dry system annual trip test and semi-annual supervisory switch inspection quarterly until substantial compliance is achieved. The results of these audits will be reviewed quarterly by the Quality Assurance and Quality Improvement committee for further analysis and recommendation.