Failure to Maintain and Inspect Fire Sprinkler System
Penalty
Summary
The facility failed to maintain, inspect, and test its fire sprinkler system as required, as evidenced by the absence of documentation for quarterly and annual testing and inspection activities. Specifically, there was no documentation available for the inspection and testing of supervisory devices, mechanical waterflow alarm devices, main drain tests, control valves, sprinkler gauges, internal valve inspections, internal pipe inspections, and obstruction investigations for the required periods. Additionally, during an observation, a sprinkler head was found to be damaged, with a frangible bulb missing its fluid. The Maintenance Supervisor and Director of Safety/Security confirmed that the required inspection reports were not on-site and acknowledged the damaged sprinkler head.
Plan Of Correction
Sprinkler system was inspected January 20th - 24th, 2025, and documentation was received from the contractor. The facility will ensure documentation is available for the survey team during all inspections. The contractor has been contacted to repair a broken sprinkler head identified during the survey. Maintenance team will monitor sprinkler heads during environmental rounds.