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 - Component: 01 - Tag: 0353
Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system to be free of obstructions, and sprinkler piping system to be free of extraneous weight, affecting two of eleven smoke compartments within the component.
Findings include:
1. Observation on February 27, 2024, between 11:00 AM and 11:06 AM, revealed sprinkler heads covered with debris, at the following locations:
a. 11:00 AM, Laundry Room Dryer Chase Room; b. 11: 03 AM, Laundry Room, dryer area; c. 11:06 AM, Laundry Room, washer area, 5 sprinkler heads.
Interview at the time of the exit conference with the Administrator and Facilities Manager on February 27, 2024, at 1:15 PM, confirmed the debris on the sprinkler heads.
2. Observation on February 27, 2024, at 12:00 PM, revealed multiple wires laying across the sprinkler pipes in B Wing, 1st floor, above the ceiling, by the Housekeeping Closet.
Interview at the time of the exit conference with the Administrator and Facilities Manager on February 27, 2024, at 1:15 PM, confirmed multiple wires laying across sprinkler pipes.
| | Plan of Correction - To be completed: 03/22/2024
1.The Maintenance Director removed debris from the laundry room sprinkler heads located in the dryer chase room area, dryer area and washer area. The Maintenance Director removed the wires laying across the sprinkler pipes located above the ceiling by the housekeeping closet on B Wing.
2.The Maintenance Director will be educated on NFPA 101 Standard Sprinkler System Maintenance and Testing on the requirement to maintain the automatic sprinkler system to be free of obstructions, and sprinkler piping system to be free of extraneous weight.
3.The Maintenance Director/designee will conduct audits of all components to verify all sprinkler heads are free of debris and sprinkler pipes are free of extraneous weight. Monthly audits of each component will be conducted to verify sprinkler heads are free of debris and sprinkler pipes are free of extraneous weight.
4.Findings will be reviewed at the Quality Assurance Performance Improvement meeting.
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