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 multiple instances, affecting two of two floors.
Findings include:
1. Observation on February 27, 2024, between 9:57 a.m., and 10:31 a.m., revealed the following:
a. 9:57 a.m., storage items were located within eighteen inches of an adjacent automatic sprinkler head within the Supplies Closet. b. 10:31 a.m., penetrations of the ceiling assembly, located within the basement-level, Wheelchair Storage.
2. Observation of facility documentation on February 27, 2024, between 10:57 a.m., and 11:07 a.m., revealed the following:
a. 10:57 a.m., the facility lacked three of four, previous, quarterly sprinkler inspections (sprinkler report, dated 2/21/23, was supplied). b. 10:58 a.m., the facility lacked five year, internal valve and internal pipe testing data, as well as five year sprinkler gauge replacement (or recalibration). c. 10:59 a.m., the facility lacked required, three year, internal tank inspection data. d. 11:00 a.m., the yearly, automatic sprinkler report, dated 2/21/23, listed the following deficiencies: "sprinkler heads in the kitchen are corroded." "Dry barrels are from 1976." "Need 2 FDC signs." "sprinkler heads in the kitchen are mixed temperatures, Link and GB." "No check valve on air line." "System due for five year internal and 3 year air leak test." Tank due for five year inspection."
Exit interview with the Facilities Manager on February 27, 2024, between 11:15 a.m., and 11:30 a.m., confirmed the automatic sprinkler deficiencies.
| | Plan of Correction - To be completed: 04/03/2024
1) The Maintenance Director as necessary other were in-serviced by the Administrator as to the requirement and importance surrounding having timely annual sprinkler and associated system inspections scheduled and conducted. The company that performed the last inspection (date correction) 2/2023, was contacted, and are scheduled to perform necessary inspection and testing of the sprinkler and associated systems April 5th, 2024, starting at 8:00am; their earliest availability. The Maintenance Director going forward, will create a tracking tool, and schedule future inspections of systems in the facility required annually, bi-annually, and other intervals as necessary, to prevent future occurrences of the same. 2) This deficiency, plan of correction, and related corrective measures to include audits, will be submitted to our QAPI Committee for review to determine effectiveness, adequacy or need for necessary change.
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