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 document review and interview, it was determined that the facility failed to meet requirements for one of two sprinkler systems.
Findings include:
1. Document review on May 10, 2022, at 8:25 a.m., revealed the last four quarterly sprinkler inspection deficiency lists noted that the three-year air leakage test had not been completed.
Interview with the maintenance supervisor on May 10, 2022, at 8:25 a.m., confirmed the three-year air leakage test had not been completed at the time of the survey.
2.Observation on May 10, 2022, at 9:03 a.m., revealed the A-Wing, resident room 22, had a missing escutcheon plate, which created a gap in the ceiling, potentially causing a delay in sprinkler activation.
Interview with the maintenance supervisor on May 10, 2022, at 9:03 a.m., confirmed the above sprinkler escutcheon plate was missing.
| | Plan of Correction - To be completed: 06/30/2022
Failure to meet requirements for Fire Sprinkler will be corrected. 1. Our outside Fire Sprinkler contractor will complete the three-year air leakage test and provide documentation for our records. 2. A- Wing, resident room 22, will have the escutcheon plate repaired by our outside Fire Sprinkler contractor to ensure safe operation of the Fire Sprinkler system.
Environmental Director or designee will review during Safety rounds and will report at the monthly QAPI meeting.
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