Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25
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Observations: Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353
Based on documentation review and interview, it was determined the facility failed to maintain the automatic sprinkler system in one instance, affecting one of eight smoke compartments.
Findings include:
1. Observation on February 14, 2024, at 9:35 a.m., revealed there were multiple unsealed ceiling penetrations in the rehabilitation storage closet on the first floor.
Interview with the Facility Administrator and Maintenance Director on February 14, 2024, at 10:35 a.m., confirmed the automatic sprinkler system deficiency.
| | Plan of Correction - To be completed: 03/22/2024
Maintenance sealed the identified unsealed penetrations in the rehab department on February 14, 2024. An audit of all other closet areas will be completed by Friday, March 8, 2024.
The maintenance director/designee will re-educate the maintenance team to look for unsealed penetrations during their weekly rounds for six weeks and then monthly for six months with work orders and repairs completed at time of discovery.
Service records will be maintained by the maintenance director to address any issues or trends related to wall penetrations. The maintenance director will present results of the routine maintenance audits and repairs regarding wall or ceiling penetrations at the Quarterly Quality Assurance Committee to address and trends that may require further follow up action.
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