|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: MAIN BUILDING 01 - Component: 01 - Tag: 0353
Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one instance, affecting the entire facility
1. Observation on April 25, 2019, at 9:00 a.m., revealed the facility lacked documentation verifying that a five year obstruction inspection of the automatic sprinkler system was performed.
Interview with the Maintenance Director on April 23, 2019, at 9:00 a.m., confirmed the five year obstruction inspection was not performed.
| ||Plan of Correction - To be completed: 05/02/2019|
Assuming for the sake of this discussion, the validity of the deficiencies noted in the Department of Health's Statement of Deficiencies Report to St Barnabas Nursing Home, Inc. for the Survey ending April 25, 2019, which St. Barnabas does not admit, we offer the following Plan of Correction. Nothing contained in the Plan of Correction shall/should be deemed an admission, either expressed or implied, on the part of St. Barnabas Nursing Home, Inc as to the validity of the deficiencies noted in the report.
We have contacted the company that performs our quarterly inspections to verify that the five year obstruction inspection was completed. A record of the original quarterly inspection dated 12/17/15 in which the five year inspection was completed and noted by J & J Fire Protection. All future documentation will note the "Date Sprinkler Checked, Who provided the system test, and the water system supply source."
The Maintenance Director or designee will review each quarterly inspection documentation, when received, to ensure that the documentation clearly notes the completion of the Five-Year Obstruction Inspection is up to date. A QA will be completed, all results reviewed by the Quality Assurance Committee.