Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its sprinkler system in accordance with NFPA 101 standards. During a Life Safety tour conducted at 1:30 pm on April 22, 2025, it was observed that the Post Indicator Valve, which is a critical component of the sprinkler system, was missing a lock. This deficiency was identified during the inspection with the Maintenance Director present. The Maintenance Director acknowledged the missing lock during a staff interview conducted at the same time as the observation. This issue was also discussed and acknowledged by the facility's Administrator during the exit conference. The lack of a lock on the Post Indicator Valve indicates a failure to adhere to the required maintenance and testing protocols as outlined in NFPA 25, which governs the inspection, testing, and maintenance of water-based fire protection systems.
Plan Of Correction
The missing lock on the post indicator valve was replaced on 04/23/2025 by the Director of Plant Operations in accordance with NFPA 25. An audit of the post indicator valve was conducted on 04/22/2025 by the Director of Plant Operations and no other locks were missing. The Plant Operations Department was educated on maintenance and Testing K353 CFR(s): NFPA 101 Sprinkler System requirements by the Regional Director of Plant Operations. Monthly audits of the post indicator valve will be completed by the Plant Operations Director or designee to determine if there are any missing locks. Findings will be taken to QAPI.