Deficiency in Sprinkler System Maintenance
Summary
The facility failed to maintain its automatic sprinkler system by not having spare sprinklers for each type and temperature rating present in the facility. During observations conducted on January 16, 2025, it was noted that the boiler room and laundry room had green vertical standard response sprinkler heads, while the server room had blue pendant standard response sprinkler heads. However, upon reviewing the spare sprinklers, only quick response sprinklers were available, and no standard response spares were present. The Director of Facility Services acknowledged the requirement to have a spare for each type of sprinkler in the facility but was unaware that their supply lacked standard response sprinklers.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 (Missing Spare Sprinklers) The Facility Services Director is currently in the process of ordering the following spare sprinkler heads and will be added to the spare sprinkler cabinet: Green vertical standard heads, Blue vertical standard heads, Red vertical standard heads, Green pendant standard heads, Blue pendant standard heads, Red pendant standard heads. The Facility Services Director will conduct an audit of all the spare sprinkler heads stored in the spare sprinkler cabinets to ensure there are no other spare heads missing from the cabinets. If there are any spare heads missing, they will be replaced in a timely manner. The Facility Services Director or designee will conduct an audit of the spare heads on a quarterly basis. The audit will be included in the Sprinkler audit form. Any deficiencies found will be corrected in a timely manner. The audits will be monitored and reported to the QAPI committee on a quarterly basis. The deficiency will be corrected no later than 3/25/25. The Facility Services Director will be responsible for this plan of correction.
Penalty
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