Sprinkler System - Out of Service Where the sprinkler system is impaired, the extent and duration of the impairment has been determined, areas or buildings involved are inspected and risks are determined, recommendations are submitted to management or designated representative, and the fire department and other authorities having jurisdiction have been notified. Where the sprinkler system is out of service for more than 10 hours in a 24-hour period, the building or portion of the building affected are evacuated or an approved fire watch is provided until the sprinkler system has been returned to service. 18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25)
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Observations: Name: MAIN BUILDING - Component: 01 - Tag: 0354
Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler protection system, in a continuously reliable operating condition, affecting one of four smoke zones within the component.
Findings include:
1. Observation on January 23, 2024, at 1:30 PM, revealed the facility failed to protect the automatic sprinkler protection system from damage, due to environmental factors. At the time of the observation, a sprinkler branch line had ruptured due to frozen water within the pipe, in the attic.
Interview with the Administrator on January 23, 2024, at 1:30 PM, confirmed the automatic sprinkler protection system had been damaged by environmental factors.
| | Plan of Correction - To be completed: 02/29/2024
1.Fire sprinkler company (Viozzi)was called immediately to make necessary repairs to the fire sprinkler system. JDS construction was called to insulate the attic. This will keep the fire sprinkler pipes protected from environmental factors. 2. Fire sprinkler system Audit was completed to ensure no other fire sprinkler pipes or sprinkler heads were affected. 3.NHA/designee will in-service the maintenance director and assistant maintenance worker on getting any finding addresses in a timely manner. 4.Director of Maintenance or Designee will report findings to the monthly QAPI meetings X 3 months.
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