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Automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. The property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems. 19.7.6, 4.6.12, NFPA 25, 4.1.4.1

Any sprinkler shall be replaced that has signs of leakage; is painted, other than by the sprinkler manufacturer, corroded, damaged, or loaded; or is in the improper orientation. NFPA 25 5.2.1.1.4

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25.

Observation determined the north sprinkler in the south walk-in freezer in the Kitchen had lost the fluid from the glass bulb.

Failure to inspect, test and maintain the automatic sprinkler system in accordance with NFPA 25 increases the risk of death or injury due to fire.

The deficiency affected one (1) of numerous locations protected by the automatic sprinkler system, which serves the entire facility.

The facility failed to conduct fire drills as required.

Fire drill records review determined no fire drill was conducted on the Night Shift during the third quarter in the past year.

Failure to conduct fire drills as required increases the risk of death or injury due to fire.

The deficiency affected one (1) of twelve (12) drills in the past year.