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M HEALTH FAIRVIEW UNIVERSITY OF MN
Sprinkler System - Installation
Tag No.: K0351
Based on observation and staff interview, the facility failed to install an approved automatic sprinkler system in accordance with the NFPA 13, Standard for Installation of Sprinkler Systems. LSC 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1). This deficient practice could affect all patients in the Unit J building.
Findings include:
On a facility tour between the hours of 9:00 AM and 12:00 PM on July 10, 2018, observation revealed that the wet stand-pipe in stairwell F of the Unit J building, had the annular space between the floor landings and the stand-pipe, filled with a hard mortar like material.
This deficient practice was verified by the Regional Facilities Director at the time of discovery.
Sprinkler System - Maintenance and Testing
Tag No.: K0353
Based on observation and staff interview, the facility did not maintain and test their automatic fire sprinkler system in accordance with NFPA 25 and the 2012 LSC NFPA 101. 9.7.5, 9.7.7, 9.7.8. This deficient practice could effect all patients in the Unit J building.
Findings include:
On a facility tour between the hours of 9:00 AM and 12:00 PM on July 10, 2018, it was revealed that the automatic sprinkler system pressure gauges, in stairwell F of the Unit J building, were dated 05/31/2012 which are older than 5 years.
This deficient practice was verified by the Regional Facilities Director at the time of discovery.
Sprinkler System - Maintenance and Testing
Tag No.: K0353
Based on observation and staff interview, the facility did not maintain and test their automatic fire sprinkler system in accordance with NFPA 25 and the 2012 LSC NFPA 101. 9.7.5, 9.7.7, 9.7.8. This deficient practice could effect all patients in the East and West buildings.
Findings include:
1. On a facility tour between the hours of 1:00 PM and 4:00 PM on July 09, 2018, it was revealed that the pre-action automatic sprinkler system pressure gauge, in the East Building on the 13th floor, was dated 03/26/2012 which is older than 5 years.
2. On a facility tour between the hours of 1:00 PM and 4:00 PM on July 09, 2018, it was revealed that the Pump Room (F6) automatic sprinkler system pressure gauge, in the West Building, was dated 03/26/2012 which is older than 5 years.
This deficient practice was verified by a facility engineer at the time of discovery.