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, to be free from extraneous weight, affecting two of seven smoke compartments within the component.
Findings include:
1. Observation on February 26, 2024, at 11:30 AM, revealed rigid ventilation ducting laying on sprinkler piping system, above ceiling by the Personal Care and Skilled Nursing separation doors.
Interview at the time of exit conference with the Maintenance Director on February 26, 2024, at 1:15 PM, confirmed the rigid ducting on the sprinkler piping system.
2. Observation on February 26, 2024, at 11:40 AM, revealed data cable and white tubing laying across sprinkler piping and a white line tied to sprinkle piping in the attic space, above Beauty Shop Room B482.
Interview at the time of exit conference with the Maintenance Director on February 26, 2024, at 1:15 PM, confirmed multiple wires, in various locations, laying across, and rope tied to the sprinkle piping system.
3. Observation on February 26, 2024, at 12:05 PM, revealed various wires laying across sprinkler piping above the ceiling, by Resident Room D230.
Interview at the time of exit conference with the Maintenance Director on February 26, 2024, at 1:15 PM, confirmed multiple wires were laying on the sprinkler piping system.
| | Plan of Correction - To be completed: 04/15/2024
The enclosed plan of correction set forth in these documents does not constitute admission or agreement by the provider of the truth of the facts alleged or concluded set forth in the statement of deficiencies. The plan of correction is prepared and or executed solely because it is required by the provision of Federal and State law.
1. Each hallway and attic in the Healthcare areas B, C and D was evaluated and checked for excessive weight on the sprinkler system. Observed areas #1, #2, and #3 were corrected to meet the sprinkler system maintenance regulation. All the corridors and attics were inspected to ensure compliance and any identified concerns related to the sprinkler protection system were corrected per the regulation. Education was provided by the Maintenance Director regarding maintaining the automatic sprinkler protection system to be free from extraneous weight.
2. An action plan was initiated, and audits will be done monthly x3 then quarterly by the QA Coordinator and Maintenance Director. The QA Coordinator will then report the findings to the QA committee quarterly to ensure compliance with this regulation. This corrective action will be completed by 4/15/24.
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