Failure to Maintain Fire Sprinkler System Documentation
Penalty
Summary
The facility failed to maintain their automatic fire sprinkler system in accordance with NFPA 101 and NFPA 25 standards. During a review of records and a facility tour conducted on April 15, 2025, it was found that there was no documentation available for the automatic fire sprinkler inspections for the first, second, and fourth quarters of 2024. The last recorded inspection was dated August 30, 2024. Additionally, there was no documentation for the 5-year backflow preventer internal inspection, and no spare sprinkler list was posted near the spare sprinkler cabinet in the riser room. These deficiencies were identified during a record review and observation conducted with the Director of Continuum and the Maintenance Supervisor, who acknowledged the findings. The lack of documentation and maintenance records indicates a failure to adhere to the required inspection and testing schedule for the fire protection system, as outlined by NFPA 101 and NFPA 25 standards. The findings were reviewed with the facility's leadership at the conclusion of the inspection.