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 - Component: 01 - Tag: 0353
Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system to be free of extraneous weight, affecting two of three floors within the component.
Findings include:
1. Observation on May 21, 2025, between 11:00 AM and 11:50 AM, revealed items were being supported by the sprinkler piping system, at the following locations:
a. 11:00 AM, 3rd floor, above ceiling, by resident room 333, various wires; b. 11:05 AM, 3rd floor, above ceiling, Common Area, above elevator doors, multiple wires; c. 11:30 AM, 2nd floor, West Hall, above ceiling, by Resident Room 233, multiple wires; d. 11:35 AM, 2nd floor, East Hall, above ceiling, by East Stairtower, various wires; e. 11:40 AM, 2nd floor, above ceiling, Common Area, above smoke doors, multiple wires and flex conduit; f. 11:50 AM, 2nd floor, above ceiling, Common Area, above elevator doors, multiple wires.
Interview with the Administrator and Environmental Service Director on May 21, 2025, at 1:30 PM, confirmed various items laying across sprinkler pipes.
| | Plan of Correction - To be completed: 06/25/2025
The Environmental Services Director inspected above the ceiling on 3rd floor and 2nd floor and removed any items being supported by the sprinkler piping system. The Environmental Service Director will educate all maintenance staff and any outside contractors to ensure items are not to be supported by sprinkler piping system. The Environmental Service Director or designee will QA above ceilings monthly for three months as well as after any contractual work is completed, then quarterly thereafter. All findings will be reported the Quality Assurance Performance Improvement Meeting for three months until compliance is maintained.
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