|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
Name: FORMERLY RENAISSANCE GARDENS AT MARIS GROVE - Component: 01 - Tag: 0353
Based on document review, observation and interview, it was determined the facility failed to maintain sprinkler components, and conduct required inspections affecting the entire facility.
1. Document review March 19, 2019, at 9:15 am, revealed documentation of a required 5-year Obstruction Inspection was unavailable at time of survey.
Interview at the exit conference with the Executive Director and the Director of Physical Plant on March 19, 2019, at 2:45 pm, confirmed the missing documentation.
2. Observation on March 19, 2019, between 1:10 pm and 1:20 pm, revealed sprinklers with buildup of debris in the following locations:
a. 1:10 pm, basement kitchen.
b. 1:20 pm, basement laundry room behind dryers.
Interview at the exit conference with the Director of Nursing and the Facilities Manager on March 19, 2019, at 2:45 pm, confirmed the sprinklers with buildup of debris.
| ||Plan of Correction - To be completed: 05/15/2019|
Responses to the cited deficiencies do not constitute an admission of agreement by the facility of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared solely as a matter of compliance with federal and/or state law.
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Waymans sprinkler company is scheduled to perform pipe obstruction test on 4/9/19 .
5 year obstruction test will be added to the sprinkler test and documented as required
Buildup of debris on sprinkler heads in the following locations
a. basement kitchen
maintenance cleaned all sprinkler heads in kitchen completed 3/22/19
b. basement laundry room behind dryers
Maintenance cleaned all sprinkler heads in laundry dryer room completed 3/22/19
Maintenance will perform ongoing monthly routine maintenance inspections on sprinkler heads to ensure that they are clean and free of debris or dust
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
A weekly random audit of the stair towers will be conducted to determine no lightbulbs are out.
What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur?
100% in service with maintenance department will occur by the maintenance supervisor or designee to ensure staff aware of light outages require immediate replacement.
How the corrective action will be monitored to ensure that the deficient practice will not recur i.e. what quality assurance programs will be established?
Monthly random audit for the next 3 months will be conducted. Negative findings will be reported to QA committee. Additional audits to be conducted as needed.