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 one instance, affecting one of seven smoke compartments.
Findings include:
1. Observation and interview with the Facility Maintenance Director on March 14, 2024, at 1:30 p.m., revealed the sprinkler head in resident room 114 located in the A-wing failed to flow water when the temperature in the room was great enough to break the glass in the sprinkler head which should have activated the sprinkler system.
Interview with the Director of Nursing on March 14, 2024, at 2:30 p.m., confirmed the automatic sprinkler system malfunctioned.
| | Plan of Correction - To be completed: 05/01/2024
Preparation, submission and implementation of the Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continuously improve the quality of care and to comply with all applicable state and regulatory requirements.
Sprinkler head in room 114 will be replaced. A sampling of 1% or 4 sprinkler heads, whichever is greater, will be completed to ensure proper functioning.
Facility utilizes TELS ensure the completion of required maintenance/inspections on the sprinkler system.
Concerns regarding the sprinkler system will be reviewed at the Quality Assurance Performance Improvement meeting.
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