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 documentation review and interview, it was determined the facility failed to maintain the automatic sprinkler system, affecting two of two floors.
Findings include:
1. Observation on February 13, 2024, at 11:55 a.m., revealed the facility lacked the following:
a. automatic sprinkler gauges, change or recalibration in the last five year period. b. five year, internal valve inspection. c. five year, internal pipe inspection.
Exit interview on February 13, 2024, between 12:15 p.m., and 12:30 p.m., with the Facility Administrator and the Facilities Manager, confirmed the automatic sprinkler system deficiency.
| | Plan of Correction - To be completed: 03/08/2024
This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because The Williamsport Home agrees with the allegations and citations listed on the statement of deficiencies. The Williamsport Home maintains that the alleged deficiencies do not, individually, and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as The Williamsport Home's written credible allegation of compliance. By submitting this plan of correction, The Williamsport Home does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and The Williamsport Home reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding.
1. The documentation for the inspections was found and sent via email to the life safety representative on 2/20/2024. The facility is in compliance with K0353. The inspection was completed within the 5-year time frame, the next inspection is due by November of 2024.
2. No auditing will need to be completed. Information for inspections will be placed in a binder.
3. The Nursing Home Administrator will work with the Maintenance Director to ensure that the inspection coming due is completed in the required time. 4. No auditing will need to be completed.
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