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
|
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0353
Based on document review, observation and interview, it was determined the facility failed to provide the 5-year sprinkler maintenance documentation, and to maintain the automatic sprinkler system, to be free of extraneous weight and obstructions, affecting the entire component.
Findings include:
1. Review of documentation on March 12, 2024, between 8:55 AM and 8:57 AM, revealed the facility lacked documentation, for the following:
a. 8:55 AM, 5-year, internal pipe inspection;
b. 8:57 AM, 5-year internal valve inspection.
Interview at the time of the exit conference with the Administrator and Maintenance Director on March 12, 2024, at 1:30 PM, confirmed the facility could not supply the 5-year testing documentation.
2. Observation on March 12, 2024, between 11:30 AM and 11:50 AM, revealed items were being supported by the sprinkler piping system, at the following locations:
a. 11:30 AM, South A Hall, by East Lounge, above the ceiling, various wires and flex ducting;
b. 11:50 AM, South A Hall, by Resident Room 25, above the ceiling, flex tubing and various wires.
Interview at the time of the exit conference with the Administrator and Maintenance Director on March 12, 2024, at 1:30 PM, confirmed various items supported by the sprinkler pipe system.
3. Observation on March 12, 2024, between 11:20 AM and 11:35 AM, revealed sprinkler heads covered with debris, at the following locations:
a. 11:20 AM, Kitchen Service Hall, 5 sprinkler heads;
b. 11:35 AM, South A Hall, between Resident Room 1 thru 7, 7 sprinkler heads;
c. 11:35 AM, South A, Nurses' Station, 3 sprinkler heads.
Interview at the time of the exit conference with the Administrator and Maintenance Director on March 12, 2024, at 1:30 PM, confirmed debris covering the sprinkler heads.
| | Plan of Correction - To be completed: 04/26/2024
The five year inspections of the internal pipes and the internal valve will be completed on 4/12/2024 by BFPE, our fire safety inspection company. The documentation will be retained in the maintenance office. The inspection report will be filed in the facility's Life Safety Binder in the maintenance office.
The inspections will continue every 5 years as required.
The maintenance director or designee will audit the life safety binder annually to ensure the documentation is present in the life safety binder.
Findings of the inspections will be presented at the facility QAPI meeting for recommendations.
The various wires and flex tubing resting on the sprinkler piping system have been secured above the pipes and no longer rest on them. Ceiling tiles have been removed throughout the building to verify there were no further locations with anything resting on the sprinkler pipes.
Anytime work is performed in the ceiling, the maintenance director or designee will inspect the work to ensure nothing is left resting on the sprinkler pipes. Anything found after work is performed will be rectified at that time.
Findings of the inspections of work performed will be presented at the facility QAPI meetings.
The sprinkler heads in the kitchen service hallway, the south hall, and the South nurse's station were cleaned.
The rest of the sprinkler heads in the building were inspected and cleaned as needed.
The sprinklers will be cleaned monthly by maintenance staff and inspected quarterly, by BFPE, our fire safety inspection company.
A copy of the inspection will be filed in the facility life safety binder in the maintenance office. The maintenance director or designee will audit the binder quarterly to ensure the documentation is present.
Findings of the audits will be presented at the facility QAPI meeting for recommendations.
the findings of the au
|
|
