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 three locations, affecting two of two floors.
Findings include:
1. Observation on February 26, 2024, between 9:10 a.m., and 10:55 a.m., revealed the following:
a. 9:10 a.m., two escutcheon plates were missing within the first floor, Main Entrance area. b. 10:00 a.m., storage items were located within eighteen inches of an adjacent sprinkler head assembly, located within the basement-level, OT/Speech Room closet. c. 10:55 a.m., two transfer grills were located within the first floor, PT/OT, ceiling assembly.
Interview at the time of the exit conference with the Adminstrator and Facilities Manager on February 26, 2024, from 11:15 a.m to 11:30 a.m., confirmed the automatic sprinkler system deficiencies.
| | Plan of Correction - To be completed: 03/27/2024
353-Sprinkler System Cited: Two escutcheon plates were replaced in lobby. Item was removed from closet in therapy gym that exceeded 18 inches to the ceiling. Two transfer grills located within the first floor, PT/OT gym ceiling were repaired. Like: Audit completed facility wide of escutcheon plates to ensure all have escutcheon plates. Education: NHA/designee will educate the Maintenance director on need for escutcheon plates, 18 inches to sprinkler heads guidance, and ceiling transfer grills. Audit: Maintenance Director/designee will audit two different areas of the facility weekly x 4 weeks to ensure items do not exceed the 18 inches to a sprinkler head and to ensure sprinklers have escutcheon plates. The results will be taken through QAPI.
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