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 BLDG 01 (ASTER,CHERRYBLOSS,TULIP,SWEETWM,PRIM - Component: 01 - Tag: 0353
Based on document review, observation, and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting the entire facility.
Findings include:
1. Document review on April 14, 2025, at 9:00 a.m., revealed the January 7, 2025, sprinkler inspection report listed the following deficiency. Evidence of corrective action was not available at time of survey.
a. Water gong is not operating properly.
Exit Interview with the Administrator and Maintenance Director on April 14, 2025, at 12:20 p.m., confirmed the sprinkler system deficiency.
2. Document review on April 14, 2025, at 9:05 a.m., revealed the facility could not produce documentation showing the following sprinkler system inspection had been conducted as required:
a. 4th quarter sprinkler inspection; b. 3-year full-flow dry system trip test.
Exit interview with the Administrator and Maintenance Director on April 14, 2025, at 12:20 p.m., confirmed the missing documentations.
3. Observation on April 14, 2025, at 11:00 a.m., revealed in the Primrose storage room, packages were directly below and within 18 inches of the sprinkler.
Exit Interview with the Administrator and Maintenance Director on April 14, 2025, at 12:20 p.m., confirmed the obstructed sprinklers.
4. Observation on April 14, 2025, at 11:37 a.m., revealed in Cherry Blossom Hall Clean Utility across from room 79 there was a sprinkler head blocked by a lighting fixture.
Exit interview with the Administrator and Maintenance Director on April 14, 2025, at 12:20 p.m., confirmed the obstructed sprinklers.
| | Plan of Correction - To be completed: 06/11/2025
#1) Sprinlker contractor has been contacted and a date certain for repair of the water gong was requested. This repair will be completed no later than June 11, 2025.
#2) Sprinlker contractor has been contacted and a date certain for completion of 3-year full-flow dry system trip test was requested. This test and report will be completed and available no later than May 31, 2025.
#3) a. Maintenance/Nursing/Kitchen & Housekeeping staff will be in-serviced on the required 18" minimum clearance allowance for sprinkler heads. b. Maintenance will install a system of tape or paint lines positioned 18" from the ceiling inside of all storage closets. This will be completed no later than June 11, 2025
#4) The 2'x4'x4" surface mounted light fixture was removed and a slim design L.E.D. strip light was installed, eliminating the sprinkler head from being blocked. Completed 5/1/25
An annual calendar indicatting the planned schedule for all required sprinkler inspections and tests will be established jointly with Peter Becker and the Sprinkler contractor. This calendar and any sprinkler/fire inspection reports from the previous month, will be reviewed monthly at the Facilities Weekly Team Meeting. Any needed repairs, recommendations or additional work indicated on the Sprinkler/Fire Reports will be reviewed and addressed for confirmation of timely completion.
The facility confirmed with the sprinkler contractor that the 4th Qtr. Sprinkler Inspection was not completed as required. The systematic changes outlined above have been put into place into place to ensure deficiency does not occur again.
Update: the 3-yr. Full-Flow Dry Trip Test was performed on 5/8/2025. All tests Passed. Report is on file and available for Surveyor review.
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