Failure to Maintain and Test Sprinkler System per NFPA 25
Penalty
Summary
The facility failed to provide required maintenance and testing for its automatic sprinkler system in accordance with NFPA 25. During a record review, it was found that the annual dry sprinkler inspection revealed the system did not pass inspection because the dry system in the attic was capped and only six sprinkler heads were active. At the time of the survey, there was no documentation available to show that corrective work was being performed or to specify which parts of the system were operational. This deficiency was confirmed by the Maintenance Director during the record review. No information was provided regarding the specific impact on residents or staff at the time of the deficiency.
Plan Of Correction
1. The facility failed to provide documentation confirming that corrective work on the dry sprinkler system was being completed to ensure proper system function. 2. Inadequate documentation and maintenance of the dry sprinkler system may compromise the safety of residents, staff, and visitors in the event of a fire emergency. 3. Corrective actions have been implemented as follows: - Excel Fire Protection replaced the 3-inch and 4-inch piping in the system. - Superiorland Electronics installed a second air compressor and replaced 12 feet of main sprinkler piping. - The system was flooded and tested; two leaks were identified (above a resident room and in the boiler room) and have been repaired. - A trip test will be conducted to confirm proper system functionality. - Both Excel and Superiorland Electronics have submitted full documentation of all repair and maintenance work to the facility. - The Maintenance Director has received training on the importance of maintaining a functional dry sprinkler system and retaining documentation of all related work. - Superiorland Electronics will complete the hydrostatic testing of the system by 5/23/25. 4. The Maintenance Director is responsible for ensuring the sprinkler system remains operational, for maintaining complete documentation of all service and repairs, and for reporting system status to the Quality Assurance (QA) Committee.