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 observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in six instances, affecting four of four smoke compartments.
Findings include:
1. Observation on June 4, 2024, revealed the following automatic sprinkler system
deficiencies:
a) 9:28 a.m., data wires and tubing were on the sprinkler pipe in the attic, above the office area;
b) 9:50 a.m., the facility failed to maintain storage below the 18-inch horizontal sprinkler plane in the colonial clean linen room;
The facility failed to maintain a smoke/heat resistive ceiling for the proper activation /operation of the automatic sprinkler system in the following locations:
c) 9:32 a.m., there was an unsealed vent pipe in the ceiling of the dietary bathroom;
d) 9:47 a.m., there were unsealed data wires above the IT equipment in the HR office;
e) 10:00 a.m., there were multiple unsealed penetrations in the ceiling of the PT modality room;
f) 10:10 a.m., there were multiple unsealed penetrations in the ceiling of the PT storage room.
Interview with the Facility Administrator and the Maintenance Director on June 4, 2024, at
1:00 p.m., confirmed the automatic sprinkler system deficiencies.
| | Plan of Correction - To be completed: 07/10/2024
1. Data wires and tubing were secured to not be laying on the sprinkler pipe in the attic above the office area. Clean linen items in Colonial hallway clean linen room were rearranged to be stored below the 18-inch horizontal sprinkler plane; red tape was added to the Colonial clean linen storage room to denote the 18-inch horizontal sprinkler plane for ease of identifying allowable space for storage. The unsealed vent pipe in the ceiling of the dietary bathroom has been sealed. The unsealed data wires above the IT in the HR office have been sealed. Penetrations in the ceiling of the PT storage room and modality room have been sealed.
2. Maintenance Director to inspect facility physical plant for additional noncompliant sprinkler pipes, clean linen rooms, vent pipes and penetrations needing to be sealed.
3. Maintenance Director educated by Regional Maintenance Director/designee on K0353.
4. NHA or designee to audit for compliance in maintaining a smoke/heat resistive ceiling for the proper activation/operation of the automatic sprinkler system weekly for four weeks and monthly for one month. Results to be submitted to QAPI for any needed additional audits or correction.
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