Failure to Maintain and Inspect Sprinkler Systems
Penalty
Summary
The facility failed to maintain and inspect its sprinkler systems in accordance with NFPA 25 standards, affecting the entire facility. During a document review, it was found that the facility could not provide documentation for a 3-year dry system full flow test and a 5-year internal valve and pipe inspection. An exit interview with the Administrator and Maintenance Director confirmed the lack of documentation. Upon a subsequent onsite revisit, it was determined that although a 5-year internal valve and pipe inspection was conducted, the dry sprinkler system did not pass inspection due to pipes being partially full of foreign materials, necessitating an internal cleaning. The blockage in the dry sprinkler pipes was confirmed during an exit interview with the Administrator and Maintenance Director.
Plan Of Correction
Internal inspection and flushing of dry system will be completed by 4/18/25. TLW to be submitted to allow for additional time to accommodate the weather to be 50 degrees or above to avoid freezing.