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: BUILDING 02 - Component: 02 - Tag: 0353
Based on document review, observation, and interview, the facility failed to maintain two of two fire sprinkler systems, affecting the entire building.
Findings include:
1.Observation and interview on March 20, 2025, at 11:43 a.m., revealed the fire alarm panel displayed a trouble signal (Trouble [1]) at the time of the survey. The maintenance supervisor communicated that the trouble signal was due to several leaks in the system piping, which resulted in the dry system being taken out of service. Documents received on March 21, 2025, noted that the facility's dry sprinkler system had been out of service since December 28, 2024, and fire watch protocols were in effect. Additional conversation revealed that the air compressor was replaced for the dry sprinkler system, but the facility failed to obtain the required approval from the Department of Health, State Plan Review, and a granted occupancy from the Life Safety Division.
Interview with the maintenance supervisor on March 20, 2025, at 11:43 a.m., confirmed the fire alarm panel displayed a trouble signal, and the dry sprinkler system was out of service.
2.Observation on March 20, 2025, at 12:40 p.m., revealed the laundry wash/wet room had a corroded sprinkler head covered with a layer of dust/lint. A build-up of material can insulate the sprinkler thermal element, impacting the temperature activation/response time of the sprinkler and/or can cause inadequate spray coverage.
Interview with the maintenance supervisor on March 20, 2025, at 12:40 p.m. confirmed the sprinkler head deficiency.
***************************
Based on observation, document review, and interview during an Onsite Revisit Survey conducted on May 14, 2025, at 8:39 a.m., it was revealed the facility submitted a Time Limited Waiver for additional time to repair the dry system and install the air compressor. The facility failed to conduct ongoing life safety measures to ensure the safety of staff and residents.
Based on document review, the fire watch day shifts for May 6, 9, 12, and 13 were not documented. In addition, the facility was unable to provide documentation for fire safety education at the time of the survey. The fire alarm system panel had a trouble signal for "2 wire det," "ground floor sprinkler." Observation at the time of the survey revealed a fire extinguisher handle seal had been broken by a cart in the corridor of the dry sprinkler system. The facility is in the process of receiving quotes to repair the system.
Interview with the maintenance supervisor on May 14, 2025, at 8:39 a.m., confirmed the facility failed to correct the items.
| | Plan of Correction - To be completed: 05/22/2025
1. Staff confirmed the fire watch was performed on specific dates; however, documentation was incomplete.
The RN Supervisor will verify that all fire watch documentation is complete at the end of each shift.
The Director of Nursing (DON) or designee will conduct audits as follows:
- 5 times a week for 1 week
- 3 times a week for the next week
- Weekly thereafter until compliance is achieved
Audits will be reviewed and presented by Director of Nursing or designee at Quality Assurance and Performance Improvement (QAPI) to ensure implemented changes have been effective.
2. All staff will receive education on fire safety and fire watch procedures.
Documentation of this education will be maintained and readily accessible.
3. Contacted Swartz Fire to service the panel immediately.
Audited the fire panel to ensure no additional trouble codes are present.
- 5 times a week for 1 week
- 3 times a week for the next week
- Weekly thereafter until compliance is achieved
Audits will be reviewed and presented by Director of Nursing or designee at Quality Assurance and Performance Improvement (QAPI) to ensure implemented changes have been effective.
4. The identified fire extinguisher with the broken seal was immediately replaced.
The facility will audit all fire extinguishers as follows:
o 5 times a week for 1 week
o 3 times a week for the next week
o Weekly thereafter until compliance is achieved
Audits will be reviewed and presented by Director of Nursing or designee at Quality Assurance and Performance Improvement (QAPI) to ensure implemented changes have been effective.
|
|
