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 - Component: 01 - Tag: 0353
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 three smoke compartments within the component.
Findings include:
1. Observation on February 7, 2024, at 11:50 AM, revealed the sprinkler head protecting the 400 Hall Soiled Linens Room was exposed at the level of the suspended ceiling, with no ceiling tile in place to restrict the passage of heat to the interstitial space above.
Interview with the Director of Maintenance on February 7, 2024, at 11:50 AM, confirmed the missing ceiling tile and exposed sprinkler head.
2. Observation on February 7, 2024, at 12:18 PM, revealed the sprinkler head closest to the corridor door within Resident Room 308 was missing an escutcheon.
Interview with the Director of Maintenance on February 7, 2024, at 12:18 PM, confirmed the missing escutcheon.
| | Plan of Correction - To be completed: 02/28/2024
1) The sprinkler head ceiling tile protecting the 400-hall soiled linen room was replaced. The escutcheon within resident room 308 was replaced.
2) A one-time facility audit will be completed to ensure each sprinkler has an escutcheon and that ceiling tiles are in place to restrict the passage of heat to the interstitial space.
3)Maintenace/designee will complete 5 random audits monthly to ensure placement of the escutcheon and ceiling tiles.
4)The QAPI committee will review monthly and provide recommendation as indicated. The committee will review monthly until a period of substantial has been achieved and maintained for a period of three months.
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