Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain and inspect its sprinkler system in accordance with NFPA 25 standards, affecting the entire facility. During a document review on April 17, 2025, it was found that the facility could not provide documentation of an annual exercise of control valves through their complete range of motion. Additionally, observations revealed physical deficiencies, including two missing sprinkler escutcheons in the oxygen room Dundale and a suspended ceiling wire improperly anchored to a sprinkler branch line in the smoke separation vestibule on the first floor, creating an external load on the sprinklers. Further observations on the same day identified another deficiency affecting one of the three levels of the facility. A missing sprinkler escutcheon was noted outside the security office and the mechanical room on the first floor. These deficiencies were confirmed during an exit interview with the Administrator and the Director of Maintenance, highlighting the facility's failure to maintain and inspect the sprinkler system adequately.
Plan Of Correction
Dunwoody will have their sprinkler vendor inspect the sprinkler control valves and will document confirmation that they exercised their complete range of motion by 5/30/2025. This will be completed and documented as part of their annual inspection going forward. Missing escutcheons will be installed by 5/30/2025 by Dunwoody Maintenance staff and checked quarterly as part of our quarterly safety inspections by the Maintenance Manager or designee. The ceiling grid wire will be removed from the sprinkler pipe by 5/30/2025 by Dunwoody's Maintenance staff. All maintenance mechanics will be inserviced on this by 5/30/2025. Missing escutcheons will be installed by 5/30/2025 by Dunwoody Maintenance staff and checked quarterly as part of our quarterly safety inspections by the Maintenance Manager or designee. All maintenance mechanics will be inserviced on this by 5/30/2025.