Failure to Maintain Automatic Sprinkler System
Penalty
Summary
The facility failed to maintain its automatic sprinkler system as required by NFPA 25, which led to deficiencies affecting the entire facility. During a document review on December 30, 2024, it was discovered that the facility did not have documentation for the semiannual inspection of the automatic sprinkler system. This lack of documentation was confirmed in an interview with the Facility Administrator and Director of Maintenance. The absence of these records indicates a failure to adhere to the necessary inspection and maintenance schedule for the sprinkler system. Additionally, observations made on the same day revealed physical deficiencies in the sprinkler system. Specifically, a sprinkler head behind the dryer room in the laundry was found to be covered in lint and dust, and another sprinkler head on the overhang at the main entrance was covered in dust. These observations were also confirmed in the interview with the Facility Administrator and Director of Maintenance. The accumulation of dust and lint on the sprinkler heads suggests a lack of regular cleaning and maintenance, which is essential for the proper functioning of the fire protection system.
Plan Of Correction
The NHA/Designee will educate the Maintenance Director/Maintenance staff on the NFPA requirements of the semiannual automatic sprinkler system inspection. The semiannual sprinkler system was conducted on February 26, May 21, August 26, and November 18, 2024. Inspections are on file at the facility. The NHA/Designee will educate the Maintenance Director/Maintenance staff on the NFPA requirements of the semiannual automatic sprinkler system inspection. The semiannual sprinkler system was conducted on February 26, May 21, August 26, and November 18, 2024. Inspections are on file at the facility.