Deficiencies in Sprinkler System Maintenance and Documentation
Penalty
Summary
The facility failed to maintain its automatic sprinkler system components, affecting two of four levels. On February 10, 2025, an observation revealed that stored boxes were placed within 18 inches of a sprinkler in the second floor C Corridor Storage Room, which was confirmed during an exit interview with the Administrator and Maintenance Director. Additionally, a missing section of drywall ceiling was replaced with white cardboard surrounding a sprinkler in the first floor Main Lobby next to the front desk, potentially affecting the sprinkler's activation. This was also confirmed during the exit interview. Further document review on the same day revealed that the facility could not provide the annual inspection documentation for the clean agent suppression system in the Basement IT Room. Additionally, a report from October 19, 2022, indicated that three butterfly valves needed replacement during a 5 Year Internal Valve Inspection, but evidence of corrective action and retesting was not available at the time of the survey. These issues were confirmed during the exit interview with the Administrator and Maintenance Director.
Plan Of Correction
A. Stored boxes were removed from the second floor C storage room to ensure proper clearance of sprinkler heads and signage/tape installed. B. White cardboard was removed from the sprinkler head on first floor main lobby next to front desk and was fixed using 5/8 sheetrock. C. Annual inspection of the clean agent suppression system by basement IT will be completed by 4/3/2025. D. 3 butterfly valves will be reinspected, and retest will be completed by 4/3/2025. All storage areas are checked to ensure proper clearance of sprinkler heads and sprinkler heads will be checked for anything that could negatively impact operation. All inspections and documentation were completed to ensure sprinkler system is in accordance with NFPA 25. Maintenance director will in-service maintenance staff on maintaining automatic sprinkler system components in accordance with NFPA 25. Random weekly audits of sprinkler system components will be completed X 3 weeks and findings reported to QAPI.