K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

REGULATION: 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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 22, 2019
Corrected date: October 1, 2019

Citation Details

Based on observations made during the Life Safety Code Survey, it was determined that for two (first and fourth floors) of eight resident use floors, the facility did not properly maintain the sprinkler system. Specifically, sprinkler heads were covered in foreign material and wires were secured to sprinkler piping. The findings are: 1. Observations on 8/13/19 at 1:55 p.m. revealed three sprinkler heads in the first-floor main kitchen were heavily coated in brown dust/debris. Two were located above the upright Traulsen cooler and one near the tray line. 2. Observations above the suspended ceiling on 8/14/19 at approximately 2:00 p.m. revealed bundles of red wires were secured to sprinkler piping at six locations outside the fourth floor elevators. 3. Observations above the suspended ceilings on 8/14/19 at approximately 2:10 p.m. revealed a bundle of three large gray electrical wires that were secured to sprinkler piping by a zip-tie and located in the first-floor exit stairwell nearest the recreation office. The 2010 edition of NFPA 13: Standard for the installation of Sprinkler Systems states: 1) Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation, 2) Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.3.5.1, 9.7.5; 2011 NFPA 25: 5.2.2.2, 5.2.1.1.1)

Plan of Correction: ApprovedSeptember 20, 2019

K 353

1) Corrective action taken for those
residents affected by the deficient practice:

A. Dust and debris was removed from the 3 sprinkler heads in the kitchen.
B. Red wires secured to sprinkler piping were removed from 6 locations outside the 4th floor elevator.
C. 3 large, gray electrical wires were removed from the sprinkler piping by the first floor stairwell

2) Corrective action taken for all residents
with the potential to be affected:

All sprinkler heads can build up dust/debris and piping can have improperly attached electrical wiring.
All sprinkler piping within the facility was reviewed to remove any improperly attached connections and for dust and debris.

3) Systemic measures that will be put into place to ensure that the deficient practice does not reoccur:

Semi-annually, maintenance will inspect and remove dust and debris from all sprinkler heads.

Maintenance personnel were inserviced on the importance of operation and cleanliness of sprinkler system components.

4) How will the corrective actions be monitored:
Monthly, maintenance will monitor 1 area per floor to verify personnel did not attach any additional wiring to sprinkler system component.
Audit results of the monthly monitoring will be reported to QA for review. Monitoring will continue until the QA committee determines the audit need is no long necessary.


5) Responsible Party

Administrator