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: 74 BLDG - Component: 01 - Tag: 0353
Based on document review, observation and interview, it was determined the facility failed to provide annual sprinkler maintenance documentation, 3-year sprinkler maintenance documentation, and the sprinkler piping system, to be free of extraneous weight, affecting the entire component.
Findings include:
1. Review of documentation on January 18, 2024, between 9:25 AM and 9:33 AM, revealed the facility lacked documentation, for the following:
a. 9:25 AM, annual Main Drain/Control Vale Test; b. 9:25 AM, monthly, 10 minutes run; c. 9:28 AM, Dry System annual Trip Test and 3-year Full Flow Trip Test; d. 9:33 AM, annual Fire Pump Inspection.
Interview at the time of the exit conference with the Administrator and Maintenance Director on January 18, 2024, at 1:45 PM, confirmed the lack of documentation for sprinkler system.
2. Observation on January 18, 2024, between 11:33 AM and 11:40 AM, revealed items were being supported by the sprinkler piping system, at the following locations:
a. 11:33 AM, lower level, above ceiling, by Director of Rehab Office, various wires; b. 11:40 AM, lower level, above ceiling, by Nurses' Station 3, insulated pipes and wires.
Interview with the Acting Administrator and Maintenance Director on January 18, 2024, at 1:45 PM, confirmed various items laying across sprinkler pipes.
| | Plan of Correction - To be completed: 02/23/2024
1. Documentation of the annual Main Drain/Control Vale Test, monthly, 10 minutes run, Dry System annual Trip Test, 3-year Full Flow Trip Test and annual Fire Pump Inspection was obtained and filed by the Maintenance Director.
2. The corrective action was completed on 2/23/2024.
3. The maintenance director or designee will conduct audits of the annual Main Drain/Control Vale Test, monthly, 10 minutes run, Dry System annual Trip Test and 3-year Full Flow Trip Test and annual Fire Pump Inspection quarterly.
4. The results of the audit will be reported monthly to the QAPI Committee for further action if necessary.
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