|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 that the facility failed to inspect and maintain the automatic sprinkler system, on five of six wings.
1. Observation on September 19, 2019, between 12:25 p.m. and 1:45 p.m., revealed the following corridor linen closets had shelves installed within eighteen inches of the closet sprinkler heads:
A. (12:25 p.m.), F wing;
B. (1:05 p.m.), D wing;
C. (1:21 p.m.), C wing;
D. (1:35 p.m.), B wing;
E. (1:45 p.m.), A wing.
Interview with the maintenance supervisor and the interim director of nursing on September 19, 2019, at 1:45 p.m., confirmed the linen closets listed above had a shelf installed within eighteen inches of the sprinkler heads.
| ||Plan of Correction - To be completed: 10/30/2019|
1. The top shelf will be removed from A, B, C, D, and F wings linen closets to ensure that there is an 18" space from the sprinkler heads.
2. Corrective action date is October 30, 2019.
3. All linen closets will be marked at the 18" so that there are no items placed above this line. Education will be completed to employees on the facility's sprinkler system policy.
4. Audits will be completed monthly by the Director of Maintenance or his designee on all linen closets to ensure items are not placed 18" from the sprinkler head. Results of these audits will be reported to the Quarterly Quality Assurance Performance Improvement Committee.