|Spinkler System - Installation|
Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers.
In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems.
22.214.171.124, 126.96.36.199, 188.8.131.52, 184.108.40.206, 220.127.116.11, 19.4.2, 18.104.22.168, 9.7, 22.214.171.124(1)
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0351
Based on observation and interview, it was determined that the facility failed to maintain installation requirements in four instances, affecting the entire facility.
1. Observation on September 19, 2019, revealed the following exterior locations contained combustible overhangs, greater than four feet, without automatic sprinkler protection:
a) 9:45 a.m., the kitchen rear exit;
b) 9:50 a.m., the employee smoking area exit;
c) 9:55 a.m., the business office hallway exit;
d) 10:00 a.m., the activities room secondary exit.
Interview with the Facility Administrator and Maintenance Director on September 19, 2019, at 1:45 p.m., confirmed the lack of automatic sprinkler protection.
| ||Plan of Correction - To be completed: 10/24/2019|
Automatic sprinkler heads will be installed in all identified locations by 10/24/19; the kitchen rear exit, the employee smoking area, the business office hallway exit, the activities room secondary exit.
The Dir of maintenance was educated on NFPA 13, specifically combustible overhangs, greater than four feet, requiring automatic sprinkler protection.