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Based on observation and interview, the facility failed to maintain the automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, 5.2.1.1, by ensuring that sprinkler heads are free of corrosion, foreign materials, paint, and physical damage and shall be installed in the correct orientation. These items could affect the operation of the heads by obstructing spray patterns, delaying the response time, and causing the heads or the entire sprinkler system to be inoperable. This deficient practice affects all staff who may be in the Laundry Room. The facility had a capacity of 17 and a census of 1 at the time of the survey.

Findings include:

Observation on 10/30/20 at 11:21 a.m., revealed the facility failed to maintain the sprinkler system in the Laundry Room. One of the sprinkler heads contained lint and dust on the head.

The Maintenance Supervisor verified this observation during the survey process.