Failure to Maintain and Document Sprinkler System Inspections and Maintenance
Penalty
Summary
The facility failed to meet sprinkler system requirements for two of three systems, as evidenced by missing documentation for required quarterly inspections and overdue trip tests. Specifically, there was no documentation for the second and third quarter sprinkler inspections, the last full-flow trip test was completed over three years prior, and the last annual partial trip test was completed more than a year ago. Additionally, a quarterly inspection noted that the system compressor had parts on order, and the facility was unable to provide further documentation due to a payment hold with the sprinkler vendor. Interviews with facility staff confirmed the lack of required documentation at the time of the survey. Further deficiencies were observed, including multiple sprinkler heads covered in dust and corrosion in the corridor outside the maintenance office and in the mechanical room inside the laboratory. These conditions were confirmed by staff interviews. During subsequent revisit surveys, it was found that the deficiencies had not been corrected, as the facility was still awaiting vendor approval and funding to schedule the necessary inspections and repairs. As a result, the facility was maintaining a continuous fire watch.
Plan Of Correction
1. Absolute Fire Protection will be contacted to ensure that: a. The fourth quarter sprinkler inspection is completed. b. The three-year, full-flow trip test is completed by April 30th, once the partial trip test verifies that the dry valves are working correctly. c. The annual partial trip test is completed by the designated "substantial compliance" date of 1/30/2026. d. Any needed parts for the system compressor are ordered, received, and installed to ensure the system compressor is operational. 2. The Administrator will assist the Environmental Services Director in ensuring that Absolute Fire Protection is contacted for service and that payment will be secured for any and all necessary parts to ensure the system compressor is operational. 3. The results of these corrective actions will be reviewed at the facility's next two quarterly Quality Assurance Performance Improvement meetings to ensure compliance. K 0353