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, observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in five instances, affecting the entire facility.
Findings include:
1. Documentation review on December 5, 2023, revealed the following automatic sprinkler system deficiencies:
a) 9:20 a.m., the facility failed to provide documentation for the required annual dry system trip test; b) 9:24 a.m., the facility failed to provide documentation for the required five year internal pipe inspection.
Interview with the Facility Administrator and the Maintenance Director on December 5, 2023, at 1:30 p.m., confirmed the facility failed to provide documention of the above deficiency at the time of inspection.
2. Observation on December 5, 2023, revealed the following automatic sprinkler system deficiencies:
a) 9:50 a.m., there were gaps in the ceiling tile of the maintenance shop greater than 1/8"; b) 10:10 a.m., there were missing ceiling tiles in the nutrition room; c) 10:25 a.m., there was a missing ceiling tile behind the dryers in the laundry room.
Interview with the Facility Administrator and the Maintenance Director on December 5, 2023, at 1:30 p.m., confirmed the automatic sprinkler system deficiencies.
****Note: During the revisit on February 1, 2024, between 8:30 a.m. and 10:00 a.m., the sprinkler deficiencies 1 a and 1 b were determined not to be completed.
Interview with Facility Administrator and on February 1, 2024, at 10:00 a.m., confirmed the sprinkler deficiencies.
| | Plan of Correction - To be completed: 02/15/2024
1. The facility has provided documentation that the annual dry system trip test and the five year internal pipe inspection is scheduled to be completed March 4th, 2024. 2. The gaps in the ceiling tile in the maintenance shop greater than 1/8 inch, missing tiles in the nutrition room and behind dryers in the laundry room have been repaired/replaced as needed. 3. The maintenance staff were in-serviced on regulation K 0353, with focus on the sprinkler system and ceiling tiles. 4. The Maintenance staff/designee completed the audit for the facility for gaps and missing ceiling tiles. 5. The missing documentation for the dry system test and five year pipe inspection will be reviewed and corrective action initiated as needed. Any concerns will be reported to the Quality Assurance Performance improvement committee. 6. The Safety Committee will review the repairs and documentation as needed to ensure all corrections are made
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