Sapphire Center for Rehabilitation and Nursing of Central Queens, LLC
June 28, 2018 Certification Survey

Standard Life Safety Code Citations

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 2, 2018
Corrected date: August 28, 2018

Citation Details

2011 NFPA 25: Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 13.4.1.3 Maintenance. 13.4.1.3.1 Internal components shall be cleaned/repaired as necessary in accordance with the manufacturer's instructions. 13.4.1.3.2 The system shall be returned to service in accordance with the manufacturer's instructions. 13.4.2 Check Valves. 13.4.2.1 Inspection. Valves shall be inspected internally every 5 years to verify that all components operate correctly, move freely, and are in good condition. This requirement is not met as evidenced by: Based on observation, staff interview and documentation review, during the recertification survey, it could not be determined that the required 5-year check valve maintenance was completed within the last five years. The findings are: During a documentation a review on 07/02/18 at approximately 9:30am, it was noted that there was no documentation provided regarding the check valve inspection completed within the last five years. In an interview on the same day at approximately 10:00am, both the Director of Maintenance, and Administrator stated the they would check with the sprinkler company for the information and provide it. The check valve maintenance documentation was not provided by the conclusion of the Life Safety Survey. 2012NFPA101 2011 NFPA 25: 13.4.1.3 10 NYCRR 415.29 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedAugust 9, 2018

Sprinkler System values,riser system check values and associated components were cleaned and adjusted by licensed sprinkler contractor as per manufactures guidelines /completed 7/27/2018
Entire building was surveyed by Maintenance Director and by licensed sprinkler contractor all systems are complainant /Completed 7/27/2018
Inspections, Testing and Maintenance of Water Based Fire Protection System/NFPA25 Policy and Procedure revised to incorporate 5 year Sprinkler obstruction testing /completed 8/8/2018
Maintenance Director will in service all Maintenance staff on new Policy and Procedures /completion date 8/14/2018

Maintenance Director will be responsible for ensuring that sprinkler system components are inspected and tested in accordance with Life Safety Code 101 NFPA 25 and for maintaining documentation
Maintenance Director is responsible for overseeing and coordinating necessary system repairs when necessary /ongoing
Testing, inspecting and maintenance of Sprinkler system value,riser system check values and associated components will be incorporated into facility wide preventative Maintenance Program and monitored quarterly via the facility wide Quality Assurance Program and will continued to be monitored for 1 (one) year therafter /ongoing